So, I work for an orthopedic group. My provider is on call in the ER. Was asked to see a patient when the ER doc could not reduce a fractured wrist. My doc sees patient in ER on 5/20. My doc admits patient to observation status on 5/21. On 5/21, my doc does a closed reduction and discharges the patient that same day. How do I bill this? Consult codes and places of service would be great. Thanks!!
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Wiki Consult in ER closed reduction performed in Observation
- Thread starter alladmins@centralcoastortho.com
- Start date
amyjph
True Blue
Was it one of these where they came in at night and it crossed midnight? What did they do in the ED on 5/20, E/M>Admit to Obsv but didn't do the closed reduction until 5/21? Why wasn't it done at the time of the ED 5/20?
What did the 5/20 consist of? I think we would need a little more info.
What did the 5/20 consist of? I think we would need a little more info.
| Admit Date: | 5/20/2023 23:39:00 | Discharge Date: | 5/21/2023 11:32:00 |
| Patient Class: | OUTPATIENT | Hospital Service: | PED |
| Chief Complaint: | Oth fractures of lower end of right radius |
"Patient had a disordered fracture that required reduction. After discussion with the patient's parent and patient we elected to proceed with procedural sedation for reduction. I do believe this was the best option for the patient's fracture. During the process of attempting reduction the distal fragment seems to keep falling off dorsally. Even with holding pressure on that area he continues to fall off into worsening dorsal angulation. Postreduction films redemonstrate this however it now at least has more length than before. Discussed the case with Dr. who reviewed the films and will plan to admit the patient, npo after midnight for OR in the morning"
My management team had the following statement however, something seems wrong with this statement but consults are confusing to me and I need clarification ladies please...
"If the patient was in the hospital for under 24 hours, it would be considered outpatient. If the patient was in the hospital 24 hours or more, that would be considered inpatient."
Attachments
amyjph
True Blue
"If the patient was in the hospital for under 24 hours, it would be considered outpatient. If the patient was in the hospital 24 hours or more, that would be considered inpatient."
The statement you quoted above is not exactly correct. A patient can be considered in observation (outpatient) status longer than 24 hours without being admitted to inpatient. In the case of the example above it is highly unlikely to never that this type case/patient would be inpatient. There could be exceptions of course. Medicare and CPT and/or commercials payers may have different instruction and rules about this.
Example:
www.novitas-solutions.com
www.novitas-solutions.com
www.facs.org
www.acep.org
What you have quoted above looks like an attempt at closed reduction note and stating they will take the patient for what looks like ORIF the next day. Just because they use the words, "plan to admit the patient" that doesn't mean admit to inpatient. You would have to look at the orders. It's most likely admit to observation pending surgery. As for an E/M there is no documentation of that in the information you have above. It's possible you may only be able to bill for the closed reduction depending on the documentation.
In the first post you said your doc closed reduced and then D/C the same day, but then the following note says, "admit the patient, npo after midnight for OR in the morning". But then the attached note says, "planning for a closed reduction versus pinning this morning". Which was it? You would need to work off the final, authenticated documentation. It's difficult to see what actually happened here. Did he see the patient in the ED only and not reduce, admit to observation, take to OR in the morning and do a closed reduction only? If so, you would see an E/M-57, and the surgery separately. Wouldn't be a consult since he took over care.
Another example, let's say Dr. ED sees the patient for the ED visit, tries to reduce, can't reduce. Calls in Dr. Ortho. Dr. Ortho comes in and does the reduction and says, yup but we have to take you for ORIF tomorrow, and you'll be under observation pending surgery. You would expect to see the ED E/M by Dr. ED (e.g. 99283), **possible** closed reduction (e.g. 25605 maybe, depends, maybe 52 mod or maybe not at all?) by Dr. ED. Dr. Ortho might only bill (25605) depending on the documentation, there would have to be enough to support a separate E/M. It is *possible* you might also bill (99222-57) depending on the documentation and/or date of service(s). It's probably not going to be a consult code because if Dr. Ortho is taking over care it's not a consult. The following day if ORIF you would probably see a code such as 25607-58, etc. depending on growth plates or not/the documentation.
Of course, you would have to consider modifiers depending on what codes were billed. It will most likely involve use of 25, 57, 58.
Also, read the CPT guidelines at the beginning of each section of the E/M codes, it explains when or when not to use the particular codes. And, consider payer which is most likely commercial or MCD in this case.
The statement you quoted above is not exactly correct. A patient can be considered in observation (outpatient) status longer than 24 hours without being admitted to inpatient. In the case of the example above it is highly unlikely to never that this type case/patient would be inpatient. There could be exceptions of course. Medicare and CPT and/or commercials payers may have different instruction and rules about this.
Example:
Understanding Inpatient vs. Observation
www.novitas-solutions.com
Observation Services Fact Sheet
www.novitas-solutions.com
2023 Changes to Reporting Inpatient and Observation Evaluation and Management Services
Learn about the changes to the hospital inpatient and hospital observation E/M codes.
www.facs.org
Observation Physician Coding FAQ
www.acep.org
What you have quoted above looks like an attempt at closed reduction note and stating they will take the patient for what looks like ORIF the next day. Just because they use the words, "plan to admit the patient" that doesn't mean admit to inpatient. You would have to look at the orders. It's most likely admit to observation pending surgery. As for an E/M there is no documentation of that in the information you have above. It's possible you may only be able to bill for the closed reduction depending on the documentation.
In the first post you said your doc closed reduced and then D/C the same day, but then the following note says, "admit the patient, npo after midnight for OR in the morning". But then the attached note says, "planning for a closed reduction versus pinning this morning". Which was it? You would need to work off the final, authenticated documentation. It's difficult to see what actually happened here. Did he see the patient in the ED only and not reduce, admit to observation, take to OR in the morning and do a closed reduction only? If so, you would see an E/M-57, and the surgery separately. Wouldn't be a consult since he took over care.
Another example, let's say Dr. ED sees the patient for the ED visit, tries to reduce, can't reduce. Calls in Dr. Ortho. Dr. Ortho comes in and does the reduction and says, yup but we have to take you for ORIF tomorrow, and you'll be under observation pending surgery. You would expect to see the ED E/M by Dr. ED (e.g. 99283), **possible** closed reduction (e.g. 25605 maybe, depends, maybe 52 mod or maybe not at all?) by Dr. ED. Dr. Ortho might only bill (25605) depending on the documentation, there would have to be enough to support a separate E/M. It is *possible* you might also bill (99222-57) depending on the documentation and/or date of service(s). It's probably not going to be a consult code because if Dr. Ortho is taking over care it's not a consult. The following day if ORIF you would probably see a code such as 25607-58, etc. depending on growth plates or not/the documentation.
Of course, you would have to consider modifiers depending on what codes were billed. It will most likely involve use of 25, 57, 58.
Also, read the CPT guidelines at the beginning of each section of the E/M codes, it explains when or when not to use the particular codes. And, consider payer which is most likely commercial or MCD in this case.
Thank you SO much for the explanation. I can't remember for sure the exact details as I had to get a claim dropped right away. I believe the ED doc tried to reduce the fracture and could not. ED doc ordered a CONSULT by my ORTHO doc. ED doc Admitted to Observation pending reduction in the morning. My ORTHO doc performed the PROCEDURE the next morning. I coded the Outpatient E/M-57 and the procedure. It was the Place of Service code and then the E/M/Consultation code (IP, OP, ER) that I was having trouble with. You answered this question in your first sentence. OP since less than 24 hours. This happens all the time and I have printed your answer. I appreciate your time"If the patient was in the hospital for under 24 hours, it would be considered outpatient. If the patient was in the hospital 24 hours or more, that would be considered inpatient."
The statement you quoted above is not exactly correct. A patient can be considered in observation (outpatient) status longer than 24 hours without being admitted to inpatient. In the case of the example above it is highly unlikely to never that this type case/patient would be inpatient. There could be exceptions of course. Medicare and CPT and/or commercials payers may have different instruction and rules about this.
Example:
Understanding Inpatient vs. Observation
Observation Services Fact Sheet
2023 Changes to Reporting Inpatient and Observation Evaluation and Management Services
Learn about the changes to the hospital inpatient and hospital observation E/M codes.Observation Physician Coding FAQ
What you have quoted above looks like an attempt at closed reduction note and stating they will take the patient for what looks like ORIF the next day. Just because they use the words, "plan to admit the patient" that doesn't mean admit to inpatient. You would have to look at the orders. It's most likely admit to observation pending surgery. As for an E/M there is no documentation of that in the information you have above. It's possible you may only be able to bill for the closed reduction depending on the documentation.
In the first post you said your doc closed reduced and then D/C the same day, but then the following note says, "admit the patient, npo after midnight for OR in the morning". But then the attached note says, "planning for a closed reduction versus pinning this morning". Which was it? You would need to work off the final, authenticated documentation. It's difficult to see what actually happened here. Did he see the patient in the ED only and not reduce, admit to observation, take to OR in the morning and do a closed reduction only? If so, you would see an E/M-57, and the surgery separately. Wouldn't be a consult since he took over care.
Another example, let's say Dr. ED sees the patient for the ED visit, tries to reduce, can't reduce. Calls in Dr. Ortho. Dr. Ortho comes in and does the reduction and says, yup but we have to take you for ORIF tomorrow, and you'll be under observation pending surgery. You would expect to see the ED E/M by Dr. ED (e.g. 99283), **possible** closed reduction (e.g. 25605 maybe, depends, maybe 52 mod or maybe not at all?) by Dr. ED. Dr. Ortho might only bill (25605) depending on the documentation, there would have to be enough to support a separate E/M. It is *possible* you might also bill (99222-57) depending on the documentation and/or date of service(s). It's probably not going to be a consult code because if Dr. Ortho is taking over care it's not a consult. The following day if ORIF you would probably see a code such as 25607-58, etc. depending on growth plates or not/the documentation.
Of course, you would have to consider modifiers depending on what codes were billed. It will most likely involve use of 25, 57, 58.
Also, read the CPT guidelines at the beginning of each section of the E/M codes, it explains when or when not to use the particular codes. And, consider payer which is most likely commercial or MCD in this case.
amyjph
True Blue
My first sentence there was a quote of what you indicated your management team told you. I was just stating that is not exactly correct. So, don't go by a rule that says it's always outpatient or observation if under 24 hours and always IP if over. This is not what I was saying.Thank you SO much for the explanation. I can't remember for sure the exact details as I had to get a claim dropped right away. I believe the ED doc tried to reduce the fracture and could not. ED doc ordered a CONSULT by my ORTHO doc. ED doc Admitted to Observation pending reduction in the morning. My ORTHO doc performed the PROCEDURE the next morning. I coded the Outpatient E/M-57 and the procedure. It was the Place of Service code and then the E/M/Consultation code (IP, OP, ER) that I was having trouble with. You answered this question in your first sentence. OP since less than 24 hours. This happens all the time and I have printed your answer. I appreciate your time
However, if you are confused about the place of service and the patient was in observation, that is typically POS 22.