Emergency Department Emergency Department Coding Handbook Coding Handbook Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer This handbook is a quick reference guide for coders in emergency department (ED) settings. It guides coders through assigning visit levels and documentation requirements for a variety of common ED services. The handbook also includes anatomical illustrations for fractures. This handbook will help you: • Determine how to report consistent visit levels based on accepted standards • Learn proper documentation for commonly performed ED procedures, such as fractures, removal of foreign bodies, and burns • Correctly assign codes for common ED procedures ##### 100 Winners Circle, Suite 300 Brentwood, TN 37027 www.hcmarketplace.com Emergency Department Coding Handbook JustCoding’s Emergency Department Coding Handbook is published by HCPro, a division of BLR Copyright © 2015 HCPro, a division of BLR All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN: 978-1-55645-730-2 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro provides information resources for the healthcare industry. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. CPT copyright 2015 American Medical Association. All rights reserved. CPT and CPT Assistant are registered trademarks of the American Medical Association. Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, Author Steven Andrews, Editor Erin Callahan, Vice President, Product Development & Content Strategy Elizabeth Petersen, Executive Vice President, Healthcare Matt Sharpe, Production Supervisor Vincent Skyers, Design Services Director Vicki McMahan, Sr. Graphic Designer Michael McCalip, Layout/Graphic Design Tyson Davis, Cover Designer Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical ques- tions. Arrangements can be made for quantity discounts. For more information, contact: HCPro 100 Winners Circle Suite 300 Brentwood, TN 37027 Telephone: 800-650-6787 or 781-639-1872 Fax: 800-785-9212 Email: [email protected] Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com Contents About the Author .............................................................v Introduction ...................................................................1 Chapter 1: Evaluation and Management ........................3 Presenting Problem .................................................................4 The Challenge of Undercoding .................................................6 Critical Care ..........................................................................7 Chapter 2: Integumentary System .................................11 Anatomy of the Skin..............................................................12 Incision and Drainage (10060–10180) ..................................12 Debridement (11000–11001), (11004–11008), (11010–11012), ((11042–11047) [11045, 11046]) ..............13 Wound Repairs (12001–13160) ...........................................19 Burns, Local Treatment (16000–16036) ..................................22 Chapter 3: Musculoskeletal System ................................27 Injection (Tendons, Muscles, Trigger Point) (20526–20553) ......27 Arthrocentesis (20600–20611) ..............................................28 Fractures ............................................................................29 Dislocations ........................................................................32 Shoulder (23500–23680) .....................................................34 Humerus (Upper Arm) and Elbow (24500–24685) ..................38 Forearm and Wrist (25500–25695) .......................................40 Hands and Fingers (26600–26785) .......................................42 Pelvic and Hip Joint (27193–27269) ......................................44 Femur (Thigh Region) and Knee Joint (27500–27566) ..............46 Leg (Tibia and Fibula) and Ankle Joint (27750–27848) ............49 Foot and Toes (28400–28675) ..............................................51 Application of Casts and Strapping (29000–29799) ................52 © 2015 HCPro Emergency Department Coding Handbook | iii About the Author Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, has served as an educator in the healthcare industry across numerous organizations over the past two decades. Her experience includes the creation and successful implementation of a Registered Health Information Technology program at a com- munity college in Northern Mississippi where she served as the pro- gram director and lead instructor for more than a decade. Her current role with TrustHCS as director of education includes overseeing ICD-10 educational offerings. As a professional educator, Scott’s experience spans a wide range of health information topics including coding, auditing, reimbursement, and healthcare law and ethics. She has trained coding staff and served in a management capacity within the HIM department. Throughout her years educat- ing, she kept a part-time job as an auditor and coder in order to stay abreast of coding and regulatory changes and updates. Throughout her career, she has also performed coding compliance audits. Scott is in the process of obtaining a doctoral degree in education. She has been honored by the Mississippi Health Information Man- agement Association with the Champion Award (2010), Educator Award (2009), and Distinguished Member Award (2007). © 2015 HCPro Emergency Department Coding Handbook | v Introduction The emergency department (ED) is a fast-paced environment that can present documentation and cases that can lead to unique coding and billing challenges. JustCoding’s Emergency Department Coding Handbook will help coders by clearly explaining how to interpret CPT® codes and guidelines in order to report procedures accurately. This easy-to-use handbook includes an explanation of evaluation and management codes for the ED and how to deal with the challenges of undercoding. The handbook also offers details on how to deter- mine critical care in order to choose the most accurate code. In the second chapter, the handbook reviews the anatomy of the integumentary system and common procedures performed on the skin. The book covers topics such as incision and drainage, debride- ment, wound repair, and burns. Finally, the third chapter details the anatomy of the musculoskeletal system and how to report procedures on those areas. Coding tips are included to tackle common questions that coders in the ED face. This chapter also reviews injection and arthrocentesis procedures, as well as application of casts and strapping. . © 2015 HCPro Emergency Department Coding Handbook | 1 1 Evaluation and Management Because the Centers for Medicare & Medicaid Services (CMS) has not created any national emergency department (ED) evaluation and management (E/M) guidelines, providers must create their own cri- teria for each visit level. CMS has developed a list of 11 criteria that it uses when auditing facility E/M criteria. According to CMS, E/M guidelines should do the following: 1. Follow the intent of the CPT® code descriptor: Guidelines should be designed to reasonably relate the intensity of hospital resources required to the different levels of effort represented by the code 2. Be based on hospital facility resources, not physician resources 3. Be clear so that they facilitate accurate payments, and be usable for compliance purposes and audits 4. Meet the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements © 2015 HCPro Emergency Department Coding Handbook | 3