ED Coding and Reimbursement Alert

Question: What procedure and diagnosis codes would you assign to this case?

A 43 -year- old patient eloped from the ED with his peripheral IV in place and returned five days later complaining of FB sensation in his arm. He may have taken it out himself while intoxicated but is not sure.

The physician documentation stated: "Attempted to remove possible FB visualized with ultrasound. In sterile fashion, the area of pain and palpable hard mass was incised & bluntly dissected. There appeared to be a thrombosed blood vessel. No foreign body was palpated or visualized. The 2.2 cm wound was closed in sterile manner with 4.0 vicryl & the skin with Dermabond, patient tolerated procedure well. Final diagnosis, thrombosed superficial upper extremity vein.

Counseled patient regarding the slight risk of retained FB but US I&D under direct visualization revealed only clots. - no FB identified."

Answer:  99284-25 (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...)

12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet); 2.5 cm or less])

76882 (Ultrasound, extremity, nonvascular, real time with image documentation; limited anatomic specific)

453.81 (Acute venous embolism and thrombosis of superficial veins of upper extremity)