Coding Emergency Visits With Procedures


Vol. 15 •Issue 22 • Page 10
Coding Corner

Coding Emergency Visits With Procedures

Case Study 1

Patient Information: 42- year-old male

Chief Complaint: Sore left eye.

History of the Present Illness: Patient is a 42-year-old male who was drilling some metal and thinks he got a piece of metal in his eye around 1300 hours. He got some of the metal out but still has some irritation. Presented for evaluation.

Current Medications: None.

Allergies: Codeine.

Review of Systems: Tetanus unknown.

Physical Examination:

• Vital Signs: Temperature 96.9, blood pressure 140/80, pulse 80, respiration 20.

• HEENT: On examination, patient has a small metal foreign body still embedded in the left cornea.

Treatment: Topical anesthetic drops were placed. Fluorescein stain was accomplished. It did show some foreign body. Foreign body was removed with a sharp pointed spatula. There was a small rust ring that was drilled clear. Patient tolerated the procedure well. Tobrex ophthalmic drops were placed in the eye, and the eye was patched closed.

Impression: Metal foreign body left cornea with removal and drilling of rust ring.

Plan: Left eye patch applied. Patient is to keep the eye patch on for 24 hours then remove the patch and begin Tobrex ophthalmic drops again, 1-2 drops in the eye four times a day for 1 week. Return to Doctor X if any other problems arise.

Hospital Code Assignments

ICD-9-CM Diagnosis Codes

930.0 Corneal foreign body

E914 Foreign body accidentally entering eye and adnexa

CPT Procedure Codes

As the procedure involved the removal of a foreign body of the cornea of the eye, check the CPT index under the word Eye. Scanning the entries under this term you will see that the correct choice is Removal. Indented under Removal is the term Foreign Body. Checking the terms indented under Foreign Body reveals that the correct choice is the Corneal without Slit Lamp. The following is the correct procedure code to assign:

65220-LT Removal of foreign body, external eye; corneal, without slit lamp (-LT Left side of body)

This case involves an emergency department (ED) service, so a code from the evaluation and management (E&M) section of the CPT manual (99281-99285 range) would need to be assigned. The code assigned depends upon your facility’s specific E&M level criteria.

Physician Code Assignments

ICD-9-CM Diagnosis Code

930.0 Corneal foreign body

E-codes are not required for physician reporting. Check with the individual payers for E-code reporting requirements.

CPT Procedure Code

For the physician claim, you would follow the same path described above to choose and assign the following code:

65220 Removal of foreign body, external eye; corneal, without slit lamp

In this case, because the patient’s condition did not require a significant separately identifiable service above and beyond the services defined in the procedure code, a separate E&M code would not be assigned for the physician. (See the E&M Services Guidelines in the 2005 CPT manual for more detailed information.)

Case Study 2

Chief Complaint: Injured left hand

History of Present Illness: The patient stumbled and fell at home sustaining an injury of her left hand with special pain at the base of the left fourth finger with some hematoma. No other complaints.

Review of Systems:

• Past History: Allergies–Capoten.

• Current Medications: Regroton, potassium and Phenobarbital.

• Social History: Non-contributory.

• Family History: Non-contributory.

Physical Examination: In the extremities, there is tenderness and ecchymotic discoloration over the MP joint of the left fourth finger. The hands have the characteristic deformity of rheumatoid arthritis.

Lab/X-ray Ordered: Left hand X-ray

ED physician’s interpretation of X-ray: Chip fracture at base of proximal phalanx, left fourth finger

Impression: Fracture proximal phalanx, left fourth finger

Treatment Plan: Finger splint applied. Post application of splint, finger re-examined by physician to check for swelling, numbness and alignment. Discharge instructions were discussed with the patient, and a prescription for Darvocet N100, 20 tablets was given. Patient was told to apply ice packs and follow up with her primary physician for referral to an orthopedist.

Hospital Code Assignments

ICD-9-CM Diagnosis Codes

816.01 Closed fracture, middle or proximal phalanx or phalanges

E885.9 Fall on same level from slip-ping/tripping/stumbling

CPT Procedure Codes

In the documentation, the ED physician states that a finger splint was placed to keep the fracture stable until the patient can see an orthopedist. Therefore, you would check the CPT manual index for the term Splint. Checking under the location of the splint—Finger—you will see the code range 29130-29131. After reading these two codes you will see that the appropriate code is the following:

29130-F3 Application of finger splint; static; (-F3 Left hand, fourth digit)

In addition to code 29130, this case involves an ED service, so a code from the E&M section of the CPT manual (99281Ð99285 range) would need to be assigned. The code assigned depends upon your facility’s specific E&M level criteria.

Physician Coding

ICD-9-CM Diagnosis Code

816.01 Closed fracture, middle or proximal phalanx or phalanges

E-codes are not required for physician reporting. Check with the individual payers for E-code reporting requirements.

CPT Procedure Code

29130 Application of finger splint; static

The patient’s condition did not require a significant, separately identifiable service above and beyond the services defined in the procedure code. Therefore, a separate E&M code would not be assigned for the physician. (See the E&M Services Guidelines in the 2005 CPT manual for more detailed information.)

Margaret Pitotti is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

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