ED Coding and Reimbursement Alert

From ear infections to fractures, get the lowdown on reporting these conditions.

Pediatric patients account for about 20 percent of all ED visits, according to data from the Agency for Healthcare Research and Quality. To examine some of the most commonly seen pediatric maladies, ED Coding Alert combed through our mailbox to extract three of the most frequently asked questions on this topic so you can report these visits correctly every time.

Double the Breathing Treatments = Double the Codes?

Scenario 1: Your ED provider administers two distinct inhalation treatments, each lasting for 55 minutes, to the same 12-year-old patient at different times on the same calendar day to treat an exacerbation of asthma. Which of the two inhalation treatment codes — 94640 or 94644 (with or without add-on +94645) — would you use, and how would you code the encounter?

Solution 1: In this particular case, you cannot use 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour); first, because the treatments are not continuous as indicated by the code’s descriptor, and second because each individual treatment lasts under an hour. So, coding the encounter as 94644 with +94645 (… each additional hour (List separately in addition to code for primary procedure) would be incorrect in this case.

Instead, if the medical record documentation reflects that the patient had, for example, one episode of care in the morning and received an inhalation treatment of 55 minutes, including start and stop times, and after being discharged, the same patient returned to the ED later that day due to continued breathing problems and received a second inhalation treatment of 55 minutes, including start and stop times, you will then bill 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) and 94640-76 (Repeat procedure or service by same physician or other qualified health care professional), since this would be a separate episode of care.

Keep in mind this service is reported by the facility, rather than the treating provider in the ED setting. “You should also document and bill for medications and supplies, so be certain to add the appropriate HCPCS J codes for medications as well as the applicable supply codes from the A codes,” says Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Get Detailed With Otitis Media

Scenario 2: Your physician documents “OM, left ear” or” Right ear otitis media,” for pediatric patients, with no other details. How can you submit the right diagnosis codes in this situation?

Solution 2: Accurate otitis media (OM) coding, like most disease coding, hinges on your ability to recognize a number of key words, which you should be able to find in the physician’s documentation. Fortunately, OM coding only requires you to know a handful of medical terms, all of which are related to the kind of fluid the ear is discharging:

This immediately enables you to determine whether to code H65.- (Nonsuppurative otitis media) or H66.- (Suppurative and unspecified otitis media).

The division is particularly useful to coders, as it enables you to code any kind of OM that involves a discharge of fluid other than pus as nonsuppurative. So, for chronic serous otitis media you would code H65.2-, while you would code H65.3- for chronic mucoid otitis media. And you would code H65.11- (Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous)) for acute and subacute exacerbations that involve the discharge of any of these fluids.

If your provider documents the cause of the OM, ICD-10 directs you to code H66.9- (Otitis media, unspecified) for cases of OM that are caused by the staphylococcal or streptococcal virus, while you would code OM due to other causes using H67.- (Otitis media in diseases classified elsewhere). The exceptions to this are B05.3 (Measles complicated by otitis media) or A38.0 (Scarlet fever with otitis media), which are both Excludes1 codes for H67.-.

Differentiate Comfort Care from Fracture Care

Scenario 3: You treat an 8-year-old patient who hurt her leg by falling off a swing. The ED physician examines the patient’s leg and documents a level four E/M visit, takes X-rays, and determines that the patient has a closed tibia fracture. The provider puts the patient’s leg in a splint, and then advises the patient to visit an orthopedist as soon as possible for additional treatment, including casting. Can you report fracture care for this?

Solution 3: The answer depends on the documentation, since even if the physician confirms a fracture, this does not guarantee that you can choose a fracture care code.

When reviewing the documentation, ask yourself whether the ED provider treated the patient’s fracture, or just made the patient more comfortable. If they just make the patient comfortable by providing stabilization and pain control, then you cannot code fracture care. To report a fracture care code, you must provide the same acute care as a specialist. In this case the ED splint was temporary, and the patient was directed to follow up with the orthopedist for a cast.

In the case described in this scenario, you should likely report an E/M service, not fracture care. On the claim, you’d report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity…) for the encounter.

If, however, the ED physician chose to reset the bone and then advised the patient to follow up with an orthopedist, you would likely be able to report the E/M and the fracture care code, such as 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction). You’d also append modifier 54 (Surgical care only) to 27752 to show that you are not coding for the patient’s follow-up care. And then you’d append modifier 57 (Decision for surgery) to the E/M to show that it was a separate service from the fracture care.