ED Coding and Reimbursement Alert

Treatment doesn't always include exploration

When a patient presents in the ED with a wound caused by a foreign object, don't assume you need a foreign-body removal (FBR), laceration, or exploration code, because sometimes the absent documentation says more than what's written. Solve this case study and see if you can navigate around these pitfalls.

Physician's documentation:

Presenting complaint: Nail in hand.

 History of present illness: Otherwise healthy left-handed roofer shot himself in the right hand with a nail gun at work three hours ago. Nail is still in place at the base of the middle finger in the palm. Last tetanus shot three years ago. No allergies. Having severe pain.

Physical examination: Vital signs reviewed. Patient is in distress due to pain. Exam otherwise limited to right hand. There is a puncture wound with a nail protruding from the palm at the base of the middle finger. Limited range of motion of that finger due to the nail and pain. Sensation intact. No significant bleeding. Capillary refill brisk. No other injuries or lacerations to the hand.

ED course of treatment: Doctor began IV and gave patient 1 gram Ancef. Median nerve block given at the wrist with good results. X-ray shows nail embedded in the head of the metacarpal bone. Discussion with hand doctor. He says to just remove the nail. Patient given 10 mg morphine IV in addition to block. Area prepped with betadine. Nail removed with pliers. Wound cleaned and dressed.

Disposition: Home on Keflex and Vicodin. Follow-up with hand doctor later this week.

Diagnosis: Foreign body (nail) embedded in third metacarpal, right hand.

How should you report this treatment and diagnosis?

Keep at Level 3 for Lack of Review

Despite the fact that the emergency department physician performed an important procedure on this patient, you don't have a code at your disposal that describes exactly what he did.

Ultimately, you should report only the nerve block (64450, Injection, anesthetic agent; other peripheral nerve or branch) and the appropriate evaluation and management code. In this case, that code is 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity), to which you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Cheryl Klarkowski, RHIT, coding specialist at Baycare Health System.

Based on the following breakdown, you can correctly report 99283. The patient's context  is "at work." You can consider "three hours ago" for duration. The injury's location  is on the patient's "right hand."

Modifying factors might be: The nail is still in place. The patient's "last tetanus shot three years ago" gives you past medical history. Forsocial history, you can use the information that he is a roofer. Systems covered by the physical examination include constitutional, musculoskeletal, integumentary, neurological, and circulatory (which you can count because of the reference to bleeding and capillary refill).

Based on the injury, intravenous medication, and procedure, the medical decision-making would qualify this case for a level four, assuming the history and physical exam met muster, says Robert LaFleur, MD,  president of Medical Management Specialists. And the nature of this presenting problem clearly "requires urgent evaluation by the physician," which is consistent with 99284. Contrast this with the definition of 99283 - which describes presenting problems of only moderate severity - and 99284 seems more appropriate.

Here's the catch: The review of systems is missing enough elements to allow you to report only a level three. The description of "severe pain" gives you the neurological system. But you don't have enough here to qualify for a level-four (99284) detailed history according to Medicare rules, so 99283 is the most appropriate code choice overall.

Don't Be Tempted by Exploration and Incision Codes

While this treatment may look as if it requires a wound care code at first glance, it does not meet the standards for wound exploration (20100-20103, Exploration of penetrating wound [separate procedure]). "Those codes are meant for more significant wounds, and there was no exploration done," LaFleur says.
Don't fall for foreign-body removal codes, either, he says. "These codes are intended for situations in which the entire foreign body lies in the muscle of tendon sheath, and the doctor has to do some digging and exploring to find it and get it out. That certainly wasn't the case here."

Hidden trap: You also can't report an incision and drainage code, even though the gaping hole in the patient's hand begs for it. These codes (10120-10121, Incision and removal of foreign body ...) include that pesky word "incision" - and the physician performed no such service, LaFleur says.

For this patient's diagnosis codes, you should report 882.1 (Open wound of hand except finger[s] alone; complicated) and E920.1 (Accidents caused by cutting and piercing instruments or objects; other powered hand tools).