ED Coding and Reimbursement Alert

Question: HPI

A 12 y.o. female presents to the ED via EMS complaining of fall and arm injury. The patient reports being at cheerleading practice this evening when she fell forward from the top of a 2-person-high pyramid. She landed on her outstretched arms, hearing and feeling a crack in her left arm. She did not hit her head or lose consciousness. On EMS arrival, the patient had a left arm deformity distal to left elbow. Her right arm was not deformed. She was put in splints and transferred to the hospital for further evaluation. In the ED, pain is 8/10. She denies other injury.

Location: arms

Quality: sharp pain

Duration: since fall earlier today

Timing: sudden onset

Modifying factors: movement of arms increases pain

Severity: moderate

Context: 12yo female fell on both outstretched arms during cheerleading practice

Associated s/s: left arm deformity

Review of Systems

Musculoskeletal: Positive for bilateral arm pain. Positive for left arm deformity.

Neurological: Negative for loss of consciousness.

All other systems reviewed and are negative.

PFSH

Past Medial: Tonsillectomy in 2010

Family: Nothing significant to this presentation

Social:  Lives with her parents and is a student

No known drug allergies

Physical Exam

Nursing note and vitals reviewed.  BP 142/81, Pulse 98, Temp 98.6, Resp. 28

Constitutional: NAD. Appears stated age.

Head: Normocephalic and atraumatic.
Ears: External ears normal.

Nose: External nose normal. No rhinorrhea.

Mouth/Throat: Airway patent. Moist mucous membranes.

Eyes: EOMI. PERRL. No scleral icterus.

Neck: Neck supple.

Cardiovascular: Normal rate, regular rhythm. Normal heart sounds. No murmur, rub, or gallop. Good pulses throughout.

Pulmonary/Chest: Clear to auscultation bilaterally. Breath sounds normal. No respiratory distress. No wheezes, rales, or rhonchi.

Abdominal/GI: Soft, non-tender, non-distended. No rebound or guarding. Bowel sounds are normal.

Musculoskeletal: upper extremities b/l in splints, pain distal to elbow b/l, skin indented on inner mid-arm, no blood, good pulses, able to move fingers and shrug shoulders, no pain proximal to elbow NVS both arms

Neurological: Alert and oriented to person, place, and time. No obvious cranial nerve deficit.

Skin: Skin is warm and dry. No rash noted. No cyanosis.
Psychiatric: Normal mood and affect. Behavior is normal.

Radiology reports ordered and reviewed.

Reviewed bilateral upper extremity X-rays  and noted fractures thru left radius and ulna and right radius

IMPRESSION:

Left radius ulna:

1.Transverse fracture through the proximal radial diaphysis with apex volar angulation.

2.Obliquely oriented fracture through the mid ulnar diaphysis with apex ulnar angulation

Right radius ulna:

1.Transverse fracture through the proximal radial diaphysis with apex volar angulation

Consulted orthopedics for treatment

Emergency Department Moderate Sedation

The patient and/or family member has consented to receive sedation to assist with completing a painful procedure(s). See nursing flow sheet for specific medication dosage and vital signs.

Pre-sedation assessment:

Airway: Airway: adequate

Mouth opening: mouth opens widely

Neck motion: good neck motion

Dentition: normal

ASA Classification: ASA 1

OSA risk factors: No risk factors

Medications used: fentanyl and propofol

Total ED Continuous attending time at bedside from sedation start: 60 minutes.

Patient tolerated procedure well.

Complications: none

Attending, MD

Medications:

ED Course:

A 12 y.o. female w/ bilateral arm fractures after a fall. On the left she has a displaced radial and ulnar fracture, and on the right a radial fracture.

- Ortho at bedside, will prepare for conscious sedation, procedure described above

- B/l reduction completed successfully 23:00

- Discharged home with ortho follow up in one week. Two slings w/ pillows under arms when resting. Oxycodone PRN for two days. Advised on splint care and when to return for care.

DX: acute fracture of left radius and ulna and right radius

Alabama Subscriber

Answer:  In this scenario, the emergency physician diagnosed the fractures of left radius and ulna and right radius but left the treatment of those injuries to the orthopedist. However, he did provide moderate sedation in support of the orthopedists' procedures, which is separately reportable to the ED E/M service if the documentation supports the time thresholds were met.

Moderate sedation codes have three criteria to consider in choosing the correct code assignment; whether the sedation is in support of the physician's own or another provider's procedure, whether the patient is under or over five years of age, and the duration of the sedation.

Since our patient is 12 years old and the sedation is in support of the orthopedist's procedures, we would first choose code 99149 that describes 30 minutes of intra-service time of sedation..

Intra service time starts with the administration of the sedation agent, requires the continued face-to-face attendance of the provider and ends at the conclusion of the personal contact by the physician providing the sedation. 

This chart states, "Total ED continuous attending time at bedside from sedation start: 60 minutes." Because the chart documents 60 minutes of intra-service time, you are also able to report code 99150 twice to capture the two additional 15 minute intra service periods.

On the claim 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...)
• Append modifier 25 to show that the E/M is separately reportable from the moderate sedation
• 99149 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time)
• 99150 (Moderate sedation services ....; each additional 15 minutes intra-service time [List separately in addition to code for primary service])