Using CPT Modifiers for ED Procedures
Margaret Pitotti, ART, CCS
The Health Care Financing Administration (HCFA) has instructed fiscal intermediaries to limit their edits of hospital claims that include CPT and HCPCS level II modifiers. Even so, it behooves coders to begin using all the modifiers when coding outpatient services as edits will be put into full force at some as-yet-undisclosed time.
Emergency department (ED) services–one area where outpatient modifiers need to be accurately assigned–generate numerous questions from coders. To reduce some of the confusion in this area, let’s look at a few examples of frequently asked coding questions.
Case 1: Repair of Single Laceration of Finger
Following a fall at home, a two-year-old female suffered a 1.5 cm laceration to the base of her left thumb. The laceration is not particularly deep but does require stitching. Topical lidocaine epinephrine tetracaine was used for local anesthesia. Three sutures of 5-0 nylon were used in a simple, interrupted fashion to close the area and reapproximate the tissue. The patient tolerated this procedure well.
Rationale and Code Assignment: In the documentation, the physician indicates only that the laceration was at the base of the thumb and gives no further details. Therefore, the appropriate modifier for left hand, thumb would be assigned to the simple repair of the 1.5 cm laceration of the thumb.
12001- FA Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less (Modifier -FA indicates the level II modifier for left hand, thumb.)
Case 2: Bilateral Removal of Foreign Body from Ears
A six-year-old presents to the ED with his mother. The mother states that the child (patient) told her he stuck seeds in both of his ears (one in each). The mother used a Q-tip to try and lift them out, but the patient screamed. On exam, the physician notes two distinct boluses of material in the ears.
The first attempt to rinse the foreign bodies out was unsuccessful. Cerumenex was then tried for 15 minutes, and both ears were rinsed again. Both seeds were successfully removed from the ears.
The patient was put on antibiotic ear drops and told to follow up in the clinic in two to three days. The diagnosis was foreign bodies, bilateral ear canals, with removal.
Rationale and Code Assignment: The ED physician successfully removed the foreign bodies (seeds) from the ears by irrigating the auditory canal and instilling Cerumenex.
Code 69200 indicates removal of foreign body in the ears, no anesthesia. Modifier -50, bilateral procedure, is added to the code to indicate that the same procedure was performed on both ears, which are organs that are bilateral in nature. The description of CPT code 69200 does not include reference to “bilateral” nor “unilateral or bilateral.”
Modifier -50, however, reflects that the procedure was performed on both ears.
When using the -50 modifier, report the CPT code only once. This guideline replaces the previous requirement to report the CPT code twice to reflect a bilateral procedure.
69200-50 Removal of foreign body from external auditory canal; without anesthesia (Modifier -50 indicates a bilateral procedure.)
Case 3: Application of Splint for Fractures on Both Arms
The patient, a 46-year-old male, was tilling his field when his tractor flipped over on its side. The patient jumped off of the tractor as it was flipping and landed hard on the road next to the field. Upon presentation to the hospital ED (hospital A), he complained of pain in the left elbow and both wrists, as well as the left side of the chest.
Except for the following, all areas of physical exam are within normal limits. Heart is rapid and irregular, but no murmurs are appreciated. Chest wall shows bruising, lateral and inferior to the left nipple with tenderness more laterally in the rib cage. The left leg has some tenderness along the anterior thigh and anterior knee with a minor abrasion noted over the thigh. The left elbow is very painful if palpated or moved in any way. The left wrist is less painful, and the right wrist is very painful as well. Pulses are good in all extremities.
Chest X-ray was obtained and shows no signs of pneumothorax. X-rays of the left elbow show significant left radial head fracture with displacement. The left wrist X-rays appear normal. The right wrist X-rays show a comminuted fracture of the distal radius.
The patient required pain medication, Toradol 30 mg intravenously, followed by morphine sulfate 2 mg intravenously.
The case was discussed with the trauma surgeon at hospital B, and the patient will be transferred by air to that center for immediate evaluation and treatment.
Prior to transport, the ED physician applied a long arm splint to the left arm for stabilization of the fractured radial head, and a short arm wrist splint (static) to the right wrist for stabilization of the fractured distal radius.
Rationale and Code Assignment: The ED physician applied splints to both arms to stabilize the fractured elbow and fractured wrist. Because the procedures performed were similar and performed on both arms, it is significant to distinguish which arm had the long arm splint applied (left) and which arm had a short arm splint applied (right). This will show that the ED procedures were performed to treat the fractures reported and differentiate the sides of the body in which the specific splints were applied.
29105-LT Application of long arm splint (shoulder to hand) (Modifier -LT indicates the left side; it is used to identify procedures performed on the left side of the body.)
29125-RT Application of short arm splint (forearm to hand); static (Modifier -RT indicates the right side; it is used to identify procedures performed on the right side of the body.)
Margaret Pitotti, a senior health care consultant with Medical Learning Inc., St. Paul, MN, has 22 years of experience in inpatient and outpatient coding and health information management.