Coding the Emergency Room Visit

Physical Exam: 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

Lab/X-ray ED Physician’s Interpretation: 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, physician re-examined finger to check for swelling, numbness and alignment. Discharge instructions were discussed with the patient, and a prescription for Darvocet N100, 20 tablets was given as well as directions to apply ice packs and follow-up with her primary physician for referral to an orthopedist.

Hospital Codes and Rationale

The emergency department (ED) physician states that a finger splint was placed to keep the fracture stable until the patient can see the orthopedist. In the CPT index, you will look up the term Splint and then Finger — 29130-29131. After reading the description of these two codes, you will see that code 29130 is the correct choice for the procedure. You must add modifier F3 to indicate that the location of the procedure was the left hand, fourth digit.

In addition to the above procedure code and modifier, an evaluation and management (E&M) code from the 99281-99285 series must be assigned to describe the level of service. Note that codes assigned for the technical component (TC) of the E&M service depend upon the specific criteria established by the hospital. Therefore, the code range that should be considered is given below, rather than a specific code. Whatever E&M code you assign must be followed by modifier 25, which will indicate a significant separately identifiable service by the same physician on the same day of the procedure.

The CPT code assignment for the hospital will look like this:

29130-F3 Application of finger splint; static

99281-99285-25 ED level of service (depending upon facility-specific criteria)

Last, but not least, you must assign the following diagnosis codes: 816.01, closed fracture, middle or proximal phalanx or phalanges and E885.9, fall on same level from slipping/tripping/stumbling.

Physician Codes and Rationale

Documentation supports assignment of a splint-application CPT code as well as an E&M code. As indicated in the above section, 29130 is the correct code for the procedure performed. Note, however, that assignment of modifier F3 for the physician assignment is “payer-specific” and you should check with your payers whether they will accept this level of modifier reporting.

The ED report supports assignment of an E&M code. After identifying the service provided, and before choosing a code from the 99281-99285 range, you must determine the extent of the history, exam and medical decision-making—the key components of the service performed.

To do this, analyze the ED report against the 1995 and 1997 E&M exam documentation guidelines issued by the Centers for Medicare and Medicaid Services (CMS). (Both sets of guidelines can be found at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.) You may use either set, whichever produces the best results for the provider. Your analysis should lead you to the following elements.

History—expanded problem focused: History of present illness, 3 elements; review of systems, 1 system; and past family and social history, 2 elements.

Exam—problem focused (both): 1997, 2 bullets (problem focused); 1995, affected area/system (problem focused).

Medical decision-making–moderate: 1 new problem with additional workup, moderate risk and minimal data to review.

From these determinations, you would assign the appropriate CPT code. First look in the index under Evaluation and Management, then Emergency Department — 99281-99288. Code 99281 (ED visit) is the correct choice, and modifier 25 should be attached to it. The ICD-9 codes assigned are identical to those assigned for the hospital.

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