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Code This!

Scenario Week of May 28, 2010:
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History of Present Illness: I was asked to consult on this 41-year-old female inpatient who presented to the emergency room this morning after she was involved in a bicycle accident on a coastal trail. She sustained head trauma, multiple facial and neck abrasions, and a left radial head fracture. Review of systems was complete and included constitutional, ENT, eyes, cardiovascular, respiratory, musculoskeletal, integumentary, and neurological with no previous problems. The patient is apparently having some numbness and tingling in her hands which is undergoing evaluation, and thought to be due to spinal cord contusion. The patient has road rash on the left cheek and left neck area. She has had several teeth lined up by oral surgery, which was performed under local anesthesia. Since having her teeth put back in place, she states her occlusion at this point feels normal. She is not having double vision. The remainder of the review of systems was normal. A complete past, family, and social history was taken and is significant for the patient being married and a smoker. She has no history of chronic illnesses. I personally reviewed the patient’s CT scan films, and they show some intracranial bleeding, though no facial fractures were appreciated.

I reviewed the plan for cleaning her road rash areas to remove the dirt from the open wounds on the left side of the face and left neck with the patient. I explained there could be some material left which would leave a tattoo, although this is fairly unusual if the wounds are cleaned out well. She will have a scar; most likely pigmentation changes will also occur, in the areas of the injuries. There is some risk of infection.

Physical Exam: Constitutional: Blood pressure 118/80, pulse 60, respirations 34. She is in no apparent distress. HEENT: Physical exam shows significant ecchymosis and swelling on the left cheek area. There is a fairly large area of deep abrasions over the malar area. There is some gray appearance to this, consistent with road tar in the wounds around the base of the nose, and in the left neck in particular there is a road rash area which has a grayish color to it, consistent with some pavement in the wound. Extraocular motions are intact. Respiratory: Clear to auscultation bilaterally, normal respiratory effort. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Musculoskeletal: Joints move within normal range of motion. Good muscle strength. A left radial head fracture is appreciated. The patient answers questions appropriately.

Assessment: Several large areas of deep road rash in the left face and neck area. These should be cleaned out under general anesthesia as it is quite painful to properly clean these areas due to the depth of the wounds. Otherwise, we may be left with a tattoo which would be very difficult to treat.

Plan: Clean the wounds under general anesthesia tomorrow morning, as the patient will be undergoing further evaluation for her other injuries.

Please assign the correct CPT and ICD-9-CM codes for the procedure above.


ANSWERS: CPT Codes — Reporting to payers other than CMS 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit.

Modifier 57 Decision for surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

CPT Codes — Reporting to CMS 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

Rationale Consult codes are selected based upon the three key elements of history, exam, and medical decision making. The history elements: Chief complaint present, HPI was extended (4+ elements), ROS was complete (10+ systems), PFSH was comprehensive (3 of 3) for a comprehensive level of history.

The exam, under 1995 guidelines, met the requirements for a detailed exam (2–7 organ systems with at least one more detail). Under 1997 guidelines, the exam met the requirements for a general multi-system expanded problem focused exam (performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s)).

Per the Medicare Physician Guide, providers may use either the 1995 Documentation Guidelines for Evaluation and Management Services or the 1997 Documentation Guidelines for Evaluation and Management Services. Medicare contractors must conduct reviews using both the 1995 and the 1997 guidelines and apply the guidelines that are most advantageous to the provider.

The medical decision making elements documented included: Number of diagnoses or management options was extensive with a new problem without additional workup. Amount or complexity of data was low (imaging personally viewed, no labs ordered or reviewed, and no old records were reviewed). Table of risk was low (minor surgery with no identified risk factors). The final level of decision making is straight forward.

NOTE: The debridement codes 11040–11044 have only 10 follow-up days and are considered by Medicare to be minor procedures.

The physician did not document time or counseling and coordination of care, so time cannot be a used as factor in the selection of the consultation code.

The history level was comprehensive, exam level was detailed problem focused, and medical decision making was low. All three key component levels must be met or exceeded for an inpatient consultation. The levels of key elements meet those required for code 99253.

Effective, January 1, 2010, CMS no longer recognizes consultation codes for Medicare part B payment. Physicians should report patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting, all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221–99223). The principal physician of record is identified by Medicare guidelines as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier AI Principal Physician of Record, in addition to the E/M code.

Using the three key elements of history, exam, and medical decision making as described above, the history level was detailed, exam level was detailed, and medical decision making was straight forward. All three key component levels must be met or exceeded for an inpatient consultation. The levels of key elements meet those required for code 99221.

In this scenario, the physician is a consultant not the attending physician, so modifier AI would not be appropriate.

According to CMS guidelines, modifier 57 Decision for surgery, should only be appended to “major surgical” procedures. CMS further identifies a major surgical procedure as one that has 90 follow-up days assigned. The debridement codes 11040–11044 have 10 follow-up days assigned; therefore, for Medicare purposes it would be inappropriate to append modifier 57. Note that private payers may request that modifier 57 be appended when determining that minor surgical procedures need to be performed.

ICD-9-CM Codes There are multiple diagnoses described in this service, but the CMS-1500 form and electronic formats allow only four diagnoses per claim. The following should be reported: 873.30 Open wound of nose, unspecified site, complicated 873.51 Open wound of cheek, complicated 874.9 Open wound of other and unspecified parts of neck, complicated E826 Pedal cycle accident

Rationale Codes 873.30, 873.59, and 874.9 are from the Injuries and Poisoning chapter of ICD-9-CM. In the ICD-9-CM Volume 2 Index, the term “Wound, open” is referenced. “Road rash” is a nonspecific term and may include superficial as well as deep wounds. If the physician classifies these as deep wounds or deep abrasions, the coder should code to “Wound, open,” by site. The physician stated the location of the road rash was the nose, which references code 873.30. Confirmation of this code in the ICD-9-CM Volume 1 Tabular Listing describes “Other open wound of head, nose complicated.” According to ICD-9-CM, open wounds include animal bites, avulsions, cuts, lacerations, puncture wounds, and traumatic amputations. The injury in the coding scenario included multiple face and neck deep abrasions; therefore, the open wound code would be appropriate. A wound considered complicated includes delayed treatment, delayed healing, foreign body, or infection. The physician documented that the wounds contained pavement and tar which warranted removal of a foreign body, so 873.30 is the appropriate choice.

The second location of the road rash was the cheek (malar). This term references code 873.51. Confirmation of this code in the ICD-9-CM Volume 1 Tabular Listing describes “Other open wound of head, face, complicated.” The physician again documented that the wounds contained pavement and tar which warranted removal of a foreign body, so 873.51 is the appropriate choice.

The third location of the road rash was the neck. This term references code 874.9. Confirmation of this code in the ICD-9-CM Volume 1 Tabular Listing describes “Other open wound of neck, other and unspecified parts, complicated.” The physician again documented that the wounds contained pavement and tar which warranted removal of a foreign body, so 874.9 is the appropriate choice.

ICD-9-CM coding instructions in these open wound categories of the nose and cheek designate a 5th digit is the highest degree of specificity available in these categories. The open wound of the neck designates a 4th digit is the highest degree of specificity available. Although other conditions are present, the provider should report those codes that relate to or affect the care rendered. Thus the other injuries would be reported by the providers who are treating those injuries.

E codes are used to permit the classification of environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effects. They are intended to be used in addition to a code from one of the main chapters of ICD-9-CM, indicating the nature of the condition, and should never be used as a primary or principle diagnosis.

 
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