ED Coding and Reimbursement Alert

Question: Chief Complaint Neck Pain following MVA

HPI

Vital signs per nurses notes
Unable to obtain History and ROS due to severe illness/injury

The patient presents with a compliant of pain to the neck area following a motor vehicle collision. There are no foreign bodies present, the onset was sudden. The pain has been resolved minutes ago after medication. The severity was severe, but is now moderate. The patient was the driver of a car in a collision hitting the passenger side of the vehicle. It is unknown if he was wearing a seatbelt at the time. He is positive for abrasions but with no bleeding contusions, loss of consciousness, vomiting and weakness. The patient does not seem to have other risk factors. Following loss of consciousness, the patient is confused and complains of neck pain.

Review of Systems

Unable to obtain because of patient confusion following LOC

Physical Exam

Constitutional: Patient is distressed, appears well developed and well nourished. Although now alert, he has difficulty following commands from repetitive questioning.
Integumentary: Color normal, warm and dry, abrasions on neck, chest and abdomen.
Musculoskeletal/Extremities: Non-tender, normal range of motion, no pedal edema or calf tenderness, NVT intact.
Neuro: Agitated, Cranial nerves normal as tested, No motor or sensory deficit noted.
Eyes: PERRL, lids and conjunctiva are normal on exam, no acute pathological process.
Cardiovascular: Regular rate and rhythm, heart sounds normal, no gallops, rubs or murmurs, no edema present.
GI/Abdomen: Soft non-tender, no organomegly, no pulsatile mass. Normal bowel sounds, abrasions present.
Neck: Diffuse cervical spine tenderness to palpation, collar in place.
Reparatory: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort.

Procedures – Physician

FAST Exam: The indications for doing this are based on him sustaining high energy blunt trauma from the MVA. FAST EXAM performed.
Cardiac Mediastinum Abdomen: The probe used for this exam was the wide convex abdominal probe. The upper right quadrant was scanned. The left upper quadrant was scanned. The suprapubic area was scanned. Normal. Findings include no fluid or blood noted in the Morisons' Pouch. No fluid noted in the splenorenal space of the LUQ. No fluid noted in the pouch of Douglas.

Orders
Medicine

NS0.9% IV1000mlRun over 30 minutes X1
Ativan Intravenous (IVP) 1 mg
Fentanyl Citrate Intravenous (IVP) 100 mcg

Lab

CBS, automated diff
Profile 16
Protime, include INR

Radiology

Chest, single view portable
CT thorax with contrast
CT cervical spine wo-p
CT of abdomen/Pelvis with contrast
MRI cervical spine

Progress Notes

Patient is feeling slightly better. Does not recall event but is speaking and awake. CT with subdural hemorrhage and Subarachnoid hemorrhage
Discussion with admitting physician over presence of significant trauma. Patient to be admitted.

Diagnosis

Subdural hemorrhage
Subarachnoid hemorrhage

Answer: In this scenario, you have a patient following an MVA with a Focused Abdominal Study for Trauma or FAST exam noted, but the findings only detail the abdominal aspect and not the echocardiography component of a FAST exam. Documentation of both anatomical areas is needed to qualify for a FAST exam and you fall short in this case because a FAST exam is captured by using two codes, 76705 (Ultrasound, abdominal, real time with image documentation limited [e.g., single organ, quadrant, follow-up]) and 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study)

This is clearly a seriously injured patient, but the history would not qualify for a level 5 ED visit without involving the acuity caveat which seems reasonable. The physician's documentation indicates that the ROS and PFSH could not be obtained because of the patient's confusion following head injury and loss of consciousness. The rest of the chart demonstrates the high severity of the encounter with a comprehensive physical exam and medical decision making of high complexity due to the admission following multiple advanced imaging both CT and MRI and ultrasound studies, labs and discussing the case with another provider. Also the use of IV Ativan would score high on the risk table. In fact, had an appropriate attestation been in place, the patient may have qualified for critical care.

On the claim report:

99285-25 (Emergency department visit for the evaluation and management of a patient...)
76705-26
ICD-10 codes to assign
S06.5X1A (Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter) for the subdural hemorrhage.
S06.6X1A (Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter) for the subarachnoid hemorrhage.