Nirali H. Patel, MDPediatric Emergency Medicine

Children’s Hospital Medical Center of Akron

4 years of Medical School 1 year of Research 3 years of Pediatric Residency 1 year of Pediatric Chief Resident 2 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.

Uses◦ 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.

Methods◦ 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 (single-layer) 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

◦ Avulsions

◦ 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 12001-12007 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.

Example◦ 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