Cases Provide Good Example of Emergency Dept. Coding

Cases Provide Good Example of Emergency Dept. Coding


Cases Provide Good Example of Emergency Dept. Coding

Kim Charland

ADVANCE Columnist

Case One: Fractured Phalanx and Subungual Hematoma
History: This is a 10-year-old male who had a 1,500-pound weight of wooden boards fall on the tip of his left long finger.

Physical Exam: There is a normal active and passive range of motion of the left long finger in both the flexion and extension. The vascular and nervous structures are intact. All the tendons are intact. There is a subungual hematoma. X-rays show a tip phalanx fracture of the left longer finger, and there is a small fracture in the jointline. The fracture requires stabilization to assure alignment.

Treatment: The left long finger was anesthetized with 2 cc of 0.5 percent Marcaine without epinephrine. Follow-ing anesthesia, the wound was cleansed. There was a 3-mm laceration on the flexor part of the distal tip of the left long finger. There was another 3-mm abrasion at the base of the nail bed for the extensor surface of the left long finger. It was elected not to suture the superficial wound after examination. The hematoma was evacuated. A static splint was applied for initial stabilization of the fracture because the finger was very swollen. The wound will be soaked three times a day in soap and water beginning tomorrow. The patient will see his private physician in two days for re-evaluation and fracture treatment.

Final Diagnoses: distal phalanx fracture, left long finger; subungual hematoma; abrasions and lacerations of the finger.

Code Assignment: The CPT codes for this case study are listed below.

29130 Application of finger splint; static

11740 Evacuation of subungual hematoma

Fractures are coded to the extent of the treatment provided. This fracture was treated by an initial application of a splint for stabilization because of swelling. The patient will be following up for definitive care in two days. A separate procedure code is needed to describe the evacuation of the hematoma.

Case Two: Cardiopulmonary Arrest
History: This afternoon at approximately 5:35 p.m., Mr. Smith suffered an apparent cardiopulmonary arrest while jogging at the health club. Paramedics were called, found the patient in ventricular fibrillation and defibrillated him x 2, which then resulted in supraventricular tachycardia with no pulses. This degenerated into a pulseless idioventricular rhythm.

Treatment: He presented to the emergency department (ED) at approximately 6:10 p.m. and resuscitation efforts were carried on there further. A central line was placed with a #8.5 French PSI introducer sheath kit in the right subclavian vein. The patient was given 2 mg of magnesium sulfate IV, a dopamine drip and a high-dose epinephrine drip.

The patient was intubated, and CPR was continued. The patient also was given atropine 2 mg IV total in two divided doses. The patient remained fixed and dilated throughout the entire resuscitation process. All through this time, the only rhythm that we had was a pulseless idioventricular rhythm that was nonperfusing. There was no return to spontaneous circulation throughout the entire resuscitative process, and the patient was pronounced dead at 6:40 p.m.

Final Diagnoses: global myocardial infarction; cardiopulmonary arrest secondary to global myocardial infarction.

Code Assignment: The CPT codes for this case study are listed below.

36489 Placement of central venous catheter (subclavian, jugular or other vein) (e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy); percutaneous, over age two

92950 Cardiopulmonary resuscitation (e.g., in cardiac arrest)

31500 Intubation, endotracheal, emergency procedure

Case Three: Foreign Body in Esophagus
History: Mr. Jones presents to the ED with a history of foreign body in his esophagus. The patient agreed to an endoscopy.

Treatment: With oral analgesia and some IV sedation, the Olympus was introduced. At the level of the cricopharyngeus, there is clearly a stricture in this area, but I could not see any foreign body. I attempted to go through this stricture with the gastroscopy, but this was unsuccessful. As I pulled the scope back, I hit a piece of hominy at the time of suction, which was obviously sitting right there in the obstruction blocking him off. The hominy was removed, and he said he felt better afterward. The scope was removed.

Because I could see some opening, I suggested that I try to dilate him. Under direct vision, I passed the guide wire through the stricture down into the stomach and then dilated him with a #27 French dilator. The stricture is very tight, and this caused him some stomach pain, so I backed off. I then took another look with the gastroscope. There is no excessive bleeding, but I could not pass the gastroscope through the stricture.

He will contact my office tomorrow and let me know how he is doing.

Final Diagnoses: cricopharyngeal obstruction, chronic; foreign body in esophagus.

Code Assignment: The CPT codes for this case study are listed below.

43215 Esophagoscopy, rigid or flexible; with removal of foreign body

43453 Dilation of esophagus, over guide wire

When assigning codes for dilations, it is important to know whether the dilation was performed with the scope in place or after the scope was removed. Documentation is often unclear. This ED report states that the gastroscope was removed prior to the dilation.

* About the author: Kim Charland, a senior health care consultant with Medical Learning Inc.(MedLearn), St. Paul, MN, has more than 10 years of experience in health information management. Her expertise includes ICD-9-CM and CPT coding for hospital ambulatory surgery, emergency and anesthesia services.

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