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CPT® Coding for Emergency Departments

Materials prepared by: Michael A. Granovsky, M.D., CPC, FACEPPresented by: Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC

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1995 vs. 1997Documentation Guidelines

• Medicare allows physicians and providers to choose between the 95 and the 97 DGs, whichever set results in the greatest benefit

• Many non Medicare payers follow Medicare documentation ‐guidelines but for specific payer policy it is necessary for physicians to confirm their state regulations and the rules of each plan they bill.

• In the ED setting, where general multi system exams are more ‐common, the 1995 DGs will typically be more favorable to the physician

• Exception ophthalmologic illnesses and injuries‐– Tend to be focused on just 1 organ system

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Emergency Department E/M Codes

• 99281• 99282• 99283• 99284• 99285• Critical Care 99291

– +99292

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ED E/M Rules• No distinction made between new and established

patients in the emergency department.

• Emergency department is defined as:“An organized hospital based facility for the provision of ‐unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

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Medical decision making dictates the highest level code that can be chosen –

Proper documentationsupports your choice.

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ED E/M Codes• 99281 ED visit for the evaluation and management of a

patient, which requires these three key components:– a problem focused history– a problem focused examination– straightforward medical decision making

Usually, the presenting problems are self limited or minor.• 99282 ED visit for the evaluation and management of a patient,

which requires these three key components:– an expanded problem focused history– an expanded problem focused examination– medical decision making of low complexity

Usually, the presenting problems are of low to moderate severity.

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99283 and 99284• 99283 ED visit for the evaluation and management of a

patient, which requires these three key components:– an expanded problem focused history– an expanded problem focused examination– medical decision making of moderate complexity

Usually, the presenting problems are of moderate severity.

• 99284 ED visit for the evaluation and management of a patient, which requires these three key components:

– a detailed history– a detailed examination– medical decision making of moderate complexity

Usually, the presenting problems are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

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Definition 9928599285 ED visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status

– – a comprehensive history– – a comprehensive examination; and– – medical decision making of high complexity

Usually, the presenting problems are of high severity and pose an immediate significant threat to life or physiologic function.

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CMS History CaveatYou must document the reason history is not obtained and documented on the record.

– NH patient with dementia– Postictal– Severe dyspnea (CHF or Asthma)

5 recognized sources for history:Family, nursing home staff/records, prior hospital charts EMS charts, EMS, personal physician

‐The physician must make reference to these notes

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The “Emergency Medicine” Caveat“If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.”

CMS 1995 Documentation Guidelines

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Documentation GuidelinesHPI ROS PFSH Exam Level of

Service1 0 0 1 99281

1 1 0 2 99282

1 1 0 2 99283

4 2 1 5 99284

4 10 2 8 99285

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Medical Decision Making

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Cautionary Note• Audit tools and coding references used by payers and practices can be

varied and different• One audit tool may place a larger emphasis on the number of necessary

differential diagnoses and list specific treatments and therapeutic options• The majority of industry accepted audit tools are reported to produce

consistent findings greater than 95 percent of the time. However, as a precaution a coder should always contact the local Medicare Carrier to request any and all available coding guides, specifically relative to E/M audit tools before conducting training with a billing physician.

• AAPC certification tests use the logic originally developed by the Marshfield Clinic and never asks a coder to make a determination on medical necessity beyond the definitions provided by the CPT, 95 and 97 DGs, and logics that are based on the Marshfield Clinic audit model

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Medical Decision MakingScoring Systems

• Most use the Marshfield Clinic Type Audit Tool to expand on the Documentation Guidelines

• Not an official part of the DGs• Tool used to score the overall Medical Decision

Making• Evaluates 3 components:

– Number of Diagnosis and Management Options– Amount- Risk

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Medical Decision Making:Number of Diagnosis orManagement Options

CPT® does not distinguish between new and established patients in the ED

• New prob. No Additional Work-up• Patient seen and discharged• New prob. Additional Work-up planned• Admit, Transfer, OR, scheduled outpatient special testing or

specifically scheduled follow up.‐

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Critical Care

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Critical Care Overview• Evaluation and Management (E/M) Code• Found in first section of CPT• Reported using 99291• Additional work reported with the add on code

+99292

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Critical Care Overview• Unlike other ED E/M codes, no specific key element

requirements

• Time based code

• Patient must meet certain clinical criteria

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Critical Care Definition“A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition..”

AMA/CPT® 2009

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Organ System Failure

• Central nervous system failure

• Circulatory failure– Acute MI

• Shock– Severe trauma– Coagulopathy

• Renal failure– New onset– Hyperkalemia

• Hepatic Failure– Encephalopathy– Stroke

• Metabolic failure– Toxic Ingestion (methanol)– Severe Acidosis

• Respiratory Failure– Pneumonia

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Critical Care Requirements• Clinical Requirement of high probability of

deterioration

• Time requirement

• Minimum 30 minutes

• Excludes separate procedures

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“Full Attention and Physician Time”• Time counted must be exclusively devoted to patient

• Does not have to be continuous

• Physician must document total time on chart

• Must document that time involved in separately billable procedures was not counted toward CC time

• Attestation with check box or fill in the blank OK

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Critical Care Time: What Counts?

• Bedside patient care• Reviewing ancillary studies• Discussions with:

– Family, rescue, nursing, physicians as related to care

• Chart documentation and completion• Bundled Procedures

– CXR

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Critical Care Bundled Services

• Cardiac Output• – 93561/93562

• CXR• – 71010/71015/71020

• Pulse Oximetry• – 94760/94761/94762

• Computer Data• – 99090

• Transcut. Pacing• 92953

• Ventilator Mgt• 94002 94004, 94660, ‐

94662

• Vascular Access• 36000/36410/36415/365

91/36600

• Gastric Intubation• 43752/91105

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Critical Care:“What is Not Included?”

• Endotracheal intubation 31500• CPR 92950• Triple Lumen Catheter insertion 36556• EKG interpretation 93010• Bill these separately

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Critical Care Time RequirementsCritical Care Time Code

<30 minutes Appropriate E/M code

30-74 99291

75-104 99291, 99292

105-134 99291, 99292 X 2

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Procedures

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What is Included in a Procedure?• Assess site/location of problem area

• Explain procedure

• Obtain consent

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CPT® and ProceduresCPT® Bundles the following:

– Local infiltration and digital block– Subsequent to the decision for surgery one related

E/M…on the date of the procedure– Immediate post operative care– Writing orders and evaluation in the PACU– Typical post operative care

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Medicare Minor Procedures• Defined as global period < 10 days

• Most have a clinically meaningful separate and distinct service to bill and add modifier 25 to E/M code

• “Visits on the same day as a minor procedure by the same physician are included in the payment for the procedure unless a significantly separately identifiable service is also performed”

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Medicare Major Procedures• Defined as global period of 90 days• Typically fracture care and dislocations in the ED.• Use modifier 57 on the E/M

”Instruct billers to use modifier 57 (decision for surgery) to identify a visit that results in the decision to perform surgery.”

MCM Section 4822

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Epistaxis Coding• Anterior Epistaxis

– Limited Cautery/Packing 30901– Extensive Cautery/Packing 30903– Nasal Tampons 30903

• Posterior Epistaxis– Packs/Cautery any method 30905‐

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Abscess Drainage• Simple or single

– Furuncle, paronychia– Superficial– Single

• Complex or multiple– Probing– Loculations– Packing

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Abscess Coding• Simple or single 10060

• Complex or Multiple 10061

• Pilonidal Abscess 10080

• Peritonsilar Abscess 42700

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Paronychia vs. Finger Abscess• Paronychia infection limited to tissue around the nail

• Finger abscess involves the finger pad

• More common now with community acquired MRSA

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Dermabond Coding• Medicare:• Single layer alone use G0168• Multiple layer with deep sutures intermediate repair

code such as 12052

• Other Payers always use laceration codes‐– Single layer face 12011– Multiple layers face 12052

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Lacerations• Codes are grouped anatomically

– Face/ears/lips/mucous membranes– Scalp/neck/extremities

• Complexity of repair:– Simple single layer‐– Intermediate layered closure‐– Complex creation of a defect, extensive undermining, ‐

retention sutures…

• Extensive cleaning and removal of debris may elevate repair from superficial to intermediate

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Complex Lac Repair• Not commonly used in ED

• Consider when drain placed

• Z and W advancement flaps uncommon

• Extensive debridement of devitalized tissue associated with complex traumatic lacerations

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•Laceration Repair

• Simple repair: the wound is superficial; involving primarily epidermis without significant involvement of deeper structures, and requires simple one layer closure.

• Intermediate repair: the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers. Single layer closure of ‐heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

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Complex Repair• Complex repair: the repair of wounds requiring more

than layered closure, such as scar revision, debridement, (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions.

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Staple and Suture Removal• Reportable only when repair performed by

another group

• Vacation areas more common

• Report low level E/M

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Foreign Body Removals• Anatomic Location

• Depth of tissue penetration

• Technique of removal– Irrigation– Incision– Dissection

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Foreign Body Removal Coding• Ear Foreign body 69200

• Nasal Foreign Body 30300

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Ocular Foreign Body Coding• Location

– Conjunctival

• Superficial 65205• Embedded 65210

– Corneal

• No slit lamp 65220• Requiring Slit lamp for removal 65222• Rust Ring Burr Tx 65435

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Coding Soft Tissue Foreign Bodies• Simple 10120 simple incision made, FB removed with

forceps• Complex 10121 requires moderate dissection,

perhaps X rays or C Arm‐ ‐• Foot separate codes

– 28190 FB in SQ– 28192 FB in deep tissues

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Toe Nail Resection Reimbursement• Avulsion of nail plate 11730

• Wedge excision, skin of nail fold 11765

• Excision of nail and nail matrix partial or complete for permanent removal 11750

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Cerumen Impaction• Technique Employed

– Irrigation (included in the EM)– Curettage

• MD Involvement• Good Procedure Note• 69210

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Splints• Physician Involvement

• Medicare

• Off the shelf

• Fiberglass/Plaster

• Fracture Care

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Splints• Replacement or initial application of splint/strap

(CPT® codes 29000 – 29799)

• Use E/M code with cast/splint/strap code

• For Medicare must be applied by Physician

• If using Fracture care code splint service is bundled

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Splint Coding• Long Leg 29505

• Long Arm 29105

• Short Leg 29515

• Short Arm 29125

• Finger 29130

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Fracture Care

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ED Physicians and Fracture Care• Emergency Physicians provide important and

meaningful fracture care• Often the first to see, treat, and stabilize injuries

involving fractures• American College of Emergency Physicians (ACEP)

strongly supports the reporting of fracture care• CPT® and Medicare (CMS) recognize the provision of

fracture care by ED physicians

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Fracture Care ReportingTo code for fracture care services the Emergency Physician must provide either “definitive” or “restorative care."

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Definitive Care• The ED physician provides the same care as the

orthopedist– Must be the same– Not a temporary measure but the same ultimate care

provided by the specialist

• Clinically fractures require a spectrum care:• Strictly supportive measures and pain control• Splinting• Casting• Operative fixation

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Definitive Care Requirement Not Met

• If the orthopedist is going to place a cast• Distal fibula fracture Tx short leg splint• Orthopedist will place a cast• Code for the short leg splint 29515• No Fracture Care Code• Moderately displaced 5th metacarpal fracture with rotational

deformity• Volar short arm splint place in the ED• Orthopedist Tx in OR with a pin• Report the splint code 29125• Do not report Fx care

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Fractures Potentially InvolvingED Definitive Care

• Fingers– No distinction between fingers or thumb– Grouped by phalanx involved: proximal &middle vs distal

– 26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each

– 26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation each

• Toes– No distinction between proximal and distal phalanx– Grouped by involvement of great toe vs other toes

– 28490 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation

– 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each

If reporting the fracture care the splinting or strapping code is not separately coded

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Fractures Generally InvolvingED Definitive Care

• Clavicle– 23500 Closed treatment of clavicular fracture– Frequently involves a sling/sling & swath

• Strapping not reported separately with Fx care• Rib– 21800 Closed treatment of rib fracture, uncomplicated, each– Frequently involves pain control, s/sx for follow up or IS

• Nose– 21310 Closed treatment of nasal bone fracture without manipulation– Frequently involves pain medication & decongestants

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Definitive CareRarely Provided for Longer Bones

• Most EDs Do not use fracture codes for:– Hips– Femurs, Tibia, Fibula– Humerus– Elbow– Forearm–Ankle and Calcaneus– Metacarpal and Metatarsal

• Rarely provide definitive care

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Restorative Care• Restorative care is provided any time the ED physician

manipulates the bones– Reduce the fracture– Restore or improve anatomic positioning

• The ED physician manipulates a distal radius (Colles) fracture– Report code 25605 closed treatment of distal radial

fracture

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CPT® DefinitionsOpen and Closed Fractures

• Closed treatment: “specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized).”

• Open treatment: “is used when the fractured bone is either (1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used or (2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site.”

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Open vs. Closed Treatment• This is a description of the technique used to treat the

fracture, not the fracture itself.• Even if the fracture itself is open the ED physician

likely did not provide open fracture care.• ED physicians almost never perform open treatment

of a fracture• ED fracture care involves closed treatment

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Modifier 54 CPT® DefinitionSurgical Care Only: “When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure number.”

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Modifier 54 Assignment• Placed on the fracture care CPT® code

• The ED physician is providing the operative care only for these fractures

• Signifies that the ED physician is not providing the post operative follow up care

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Fracture CareE/M Modifiers Medicare Rules

• Medicare construct• Global Surgical package

– Minor procedures (0 10 day global)‐

• Laceration repair– Major procedures (>10 day global)

• Fracture Codes have a 90 day global• For major procedures Medicare requests applied to the E/M

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Fracture Care Codes“Without” vs. “With Anesthesia”

• The AMA and CPT® have stated that the “with anesthesia codes” are to be used in the Operating Room Setting with general anesthesia.

• These codes do not apply to the ED setting.

• Even if Moderate Conscious Sedation or Deep Sedation employed report the “without anesthesia” codes.

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Dislocation Codes• Use dislocation codes for any documented reductions

– Fingers and Toes– Shoulders– Hips– Ankles– Patella– Mandible– Elbow

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Moderate Conscious Sedation

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Moderate Conscious Sedation• Patient responds purposefully to verbal commands

with light tactile stimulation

• No interventions are required to maintain a patent airway

• Spontaneous ventilation is adequate

• Cardiovascular function is maintained

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Moderate Conscious Sedation• Codes divided into 2 groups:• MCS provided by the same physician who is

performing the procedure– Requires an independent trained observer

• MCS provided by a physician in support of a second health care provider performing the procedure

• Each group further delineated based on age of patient and time increments

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MCS Same Physician:99143, 99144, 99145

• Moderate sedation by same doctor performing the procedure

• 99143: Under 5 y.o. first 30 minutes.‐

• 99144: 5 y.o. and over first 30 minutes.‐

• +99145: each additional 15 minutes.– Add on Code

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MCS Different Physician:99148, 99149, 99150

• Moderate sedation by different doctor from the one performing the procedure

• 99148: Under 5 y.o. first 30 minutes.• 99149: 5 y.o. and over, first 30 minutes.• +99150: each additional 15 minutes.

– Add on Code

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MCS: Intra Service Time• Intra service time starts with the administration of ‐

the sedation agents

• Required continuous face to face attendance‐ ‐

• Ends at the conclusion of personal contact by the physician providing the sedation

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MCS and Appendix G Issues• Appendix G lists ~250 codes that bundle CS• ED Important codes:

– 32551 chest tube insertion– 33010 pericardiocentesis– 33210 insertion transvenous pacemaker– 36555 insertion pediatric (under age 5) central line– 36568 insertion pediatric (under age 5) PICC line– 92953 transcutaneous pacing– 92960 elective cardioversion

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MCS and Appendix G Codes• Do not report MCS for an Appendix G procedure

when only a single physician involved• Do not report codes 99143 99145 with Appendix G ‐

procedures• You may report MCS for an Appendix G procedure

when provided by a different physician other than the one performing the procedure

• Do report codes 99148 99150 with Appendix G ‐Procedures

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Fracture Care ExampleFRACTURE CARE: Performed by attending. Prior to

procedure, capillary refill normal. Compartment is normal. Distal sensation is intact. Distal motor function is normal. Left wrist fracture noted. Closed treatment of colles wrist fracture without manipulation completed. X-ray ordered. Short arm post mold applied. Material used for splinting is plaster. Orthopedic device applied in position of comfort. Post splinting neurovascular check. Capillary refill normal, distal sensation is intact, distal motor function is normal. Patient tolerated procedure well.

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Fracture Care ExampleFRACTURE CARE: Performed by attending. Prior to

procedure, capillary refill normal. Compartment is normal. Distal sensation is intact. Distal motor function is normal. Left wrist fracture noted. Closed treatment of colles wrist fracture without manipulation completed. X-ray ordered. Short arm post mold applied. Material used for splinting is plaster. Orthopedic device applied in position of comfort. Post splinting neurovascular check. Capillary refill normal, distal sensation is intact, distal motor function is normal. Patient tolerated procedure well.

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Splint Coding ExampleIntervention Xray: Right tibia fibula and foot negative

for acute bony injuryImmobilization was achieved by the application of OCL

stirrup short leg splint applied by ERMDImmobilization device was then check to assure good

neurovascular flow and effectiveness of positioning by me before the patient was discharged

Crutches dispensed. Crutch walking safely with good use of crutches

Follow up: Instructions given to follow up with MD or orthopedics in 4-5 days. May return to ER or orthopedics sooner for worsening symptoms.

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Splint Coding ExampleIntervention Xray: Right tibia fibula and foot negative

for acute bony injuryImmobilization was achieved by the application of OCL

stirrup short leg splint applied by ERMDImmobilization device was then check to assure good

neurovascular flow and effectiveness of positioning by me before the patient was discharged

Crutches dispensed. Crutch walking safely with good use of crutches

Follow up: Instructions given to follow up with MD or orthopedics in 4-5 days. May return to ER or orthopedics sooner for worsening symptoms.

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Incision and Drainage Example42-year-old man presents to the ED with multiple

small abscesses on his lower back. The areas are localized, erythematous, fluctuant and swollen. The affected areas were prepped with Betadine. A 1% Lidocaine local block was used on all four areas. The abscess was incised with a #11 blade, positive moderate purulent material was expressed from all areas, hemostat used to breakup loculations, cavities were irrigated until clear drainage. Incision sites packed with vaseline gauze Areas were covered with a sterile nonadherent dressing. Patient tolerated the procedure well.

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Incision and Drainage Example42-year-old man presents to the ED with multiple

small abscesses on his lower back. The areas are localized, erythematous, fluctuant and swollen. The affected areas were prepped with Betadine. A 1% Lidocaine local block was used on all four areas. The abscess was incised with a #11 blade, positive moderate purulent material was expressed from all areas, hemostat used to breakup loculations, cavities were irrigated until clear drainage. Incision sites packed with vaseline gauze Areas were covered with a sterile nonadherent dressing. Patient tolerated the procedure well.

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Laceration Repair ExampleProcedure: Laceration repair description: 13 cm linear laceration on right

upper forehead, shape linear.Wound prep: Betadine, Wound irrigation: Saline, Foreign body

removal: yes, multiple pieces of dirt and gravel removed by hand and irrigation, re-explored and no dirt or FBs seen.

Local anesthesia: Lidocaine:1%, with epinephrine, 10cc sqRepair: 2 layers, deep layer repaired with simple interrupted

absorbable 3-0 vicryl sutured and skin layer repaired with staples, 13 staple.

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Laceration Repair ExampleProcedure: Laceration repair description: 13 cm linear laceration on right

upper forehead, shape linear.Wound prep: Betadine, Wound irrigation: Saline, Foreign body

removal: yes, multiple pieces of dirt and gravel removed by hand and irrigation, re-explored and no dirt or FBs seen.

Local anesthesia: Lidocaine:1%, with epinephrine, 10cc sqRepair: 2 layers, deep layer repaired with simple interrupted

absorbable 3-0 vicryl sutured and skin layer repaired with staples, 13 staple.

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Moderate Conscious Sedation ExampleThe patient was prepared in Room 2 for procedural

sedation and reduction of his upper extremity fracture. Patient was given 30 mg of ketamine IV, approximately 1.5 mg/kg by me. This had good effect as the reduction was tolerated reasonably well and uncomplicated. Patient was thoroughly monitored during the reduction, with no complications. The reduction was performed by Dr. O of orthopedics MCS by ERMD. Patient was recovered in emergency department, discharged in the care of his family in improved and stable condition. He will follow up with orthopedics as directed. Sedation time: 30 minutes

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Moderate Conscious Sedation ExampleThe patient was prepared in Room 2 for procedural

sedation and reduction of his upper extremity fracture. Patient was given 30 mg of ketamine IV, approximately 1.5 mg/kg by me. This had good effect as the reduction was tolerated reasonably well and uncomplicated. Patient was thoroughly monitored during the reduction, with no complications. The reduction was performed by Dr. O of orthopedics MCS by ERMD. Patient was recovered in emergency department, discharged in the care of his family in improved and stable condition. He will follow up with orthopedics as directed. Sedation time: 30 minutes

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