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Nirali H.

Patel, MD Pediatric Emergency Medicine Childrens Hospital Medical Center of Akron

4 1 3 1 2

years of Medical School year of Research years of Pediatric Residency year of Pediatric Chief Resident years of Pediatric Emergency Fellowship

Total: 11 Years of Medical Experience

Estimate 80 hours work week (conservative!)

80 hrs x 52 weeks/yr x 11 yr 45,760 hours

A: 0-10 hours

B: 11-20 hours
C: 21-30 hours D: 31-40 hours

Article published May 2010 in Western Journal of Emergency Medicine

Surveyed 34 EM residents and 22 EM attendings regarding overall comfort of billing and coding 91% of Residents and 95% of Attendings felt that their jobs will require knowledge in billing & coding Only 26% and 29% felt they had adequate education in billing and documentation during residency

According to a 2004 Article in Emergency Medicine Clinics of North America, surgical and diagnostic procedures performed in the ED are considered separate services for coding purposes.
A billable service is one listed in the CPT manual that is performed as described. Includes orthopaedic procedures, laceration repairs, foreign body removals, CPR.

Support and protect injured bones and soft tissue. Reduce pain, swelling, and muscle spasm. Decrease movement Provide support and comfort through stabilization of an injury. Secure nonemergent injuries to bones until they can be evaluated by orthopaedics.

Advantages & Disadvantages

Unlike casts, splints are noncircumferential and often preferred in the emergency department setting, since injuries are often acute and continued swelling can occur. Splints or "half-casts" provide less support than casts. However, splints can be adjusted to accommodate swelling from injuries easier than enclosed casts.

Custom Made: especially if an exact fit is necessary. Ready-made splint:
Off-the-shelf splints Variety of shapes and sizes Easier and faster to use Easy to adjust, and to put on and take off due to velcro straps

Finger Splints Thumb Spica Splint Volar Splint Dorsal Splint Teardrop Splint Boxer Splint Reverse Sugar Tong Elbow Splint

Knee Immobilizer Ankle Stirrup Posterior Ankle Posterior Leg

Laceration coding depends on three variables

Repair complexity Wound location Wound size

CPT groups laceration repairs broadly into three categories, by extent of repair.
Simple Intermediate Complex

Simple (singlelayer) repairs (12001-12018, APC 0133) involve

Epidermis Dermis Subcutaneous Tissue No signifiant involvement of deeper tissue.

Intermediate repairs (12031-12057, APCs 0133 and 0134) involve

Deeper layers
Subcutaneous tissue Superficial (non-muscle) fascia Skin (epidermal and dermal) closure.

Layered closure. Heavily contaminated wounds requiring extensive cleaning may qualify as an intermediate repair, even if single layer sutures.

Complex repairs (13100-13153, APCs 0134 and 0135)

Involve more than layered closure
Extensive undermining Stents Retention sutures

Extensive revision or repair of traumatic lacerations

Reconstructive or creation of a defect to be repaired (scar excision with subsequent closure).

Within each level of repair, CPT categorizes wounds by anatomic location. For example, simple repair codes 1200112007 apply to wounds of the neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet).

Determine code choice according to repair complexity and anatomic location for each wound
Then select final code according to the size of the repaired wound(s).

Multiple Wounds
CPT treats all repairs of the same severity and within the same anatomic classification as a single, cumulative wound Choose one code only to describe two or more repairs of the same severity in the same anatomic category.


Surgeon repairs lacerations on both hands (3 cm and 5 cm) and the left arm (9 cm). All repairs qualify as intermediate because the physician must remove particulate matter from the wounds, in addition to simple closure. To report repair of the hand wounds, add together the individual 3-cm and 5-cm lacerations for a total size of 8 cm Report 12044: Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12 cm For the arm wound, select 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm

Traumas or Cardio respiratory Arrests

Chaotic Documentation Includes
Intubations Central Lines Intraosseous Lines Thoracocentesis and Thoracotomy Tubes

In the ED, will not be an elective intubation.

Emergent intubation usually preceded by Rapid Sequence Intubation (RSI)

Endotracheal intubation, emergency (CPT 31500)

Use this code in emergency or crisis situations, not for elective intubation Documentation should support an emergent need through appropriate coding

Critical care codes

Intubations are considered separately billable procedures from critical care services Must subtract the time you spend on these procedures from the time you bill for critical care services

Multiple Sites
Requires Sterile Site

Associated with more risks and complications

Usually requires a specialist

When IV access has failed Does not require sterilization or specialist

Used to rapidly obtain access

Used for air in the lungs causing difficulty breathing (Tension Pneumothorax)

For blood or fluid in the lungs or lung lining (hemothorax, pleural effusion) or large pneumothorax
Sterile procedure May be done under conscious sedation in stable patients or while patient is intubated during resuscitation