Test Your CPT Coding Knowledge for Penetrating Trauma

CODING AND PRACTICE MANAGEMENT CORNER

Test your CPT coding knowledge for penetrating trauma

by Jayme Lieberman, MD, FACS; Christopher Senkowski, MD, FACS; Charles Mabry, MD, FACS; and Jan Nagle, MS

revious Bulletin articles thigh level. The emergency of all wounds, the tourniquet have provided Current medical service providers had is let down and hemostasis is PProcedural Terminology applied a tourniquet in the field, obtained. A 100 sq cm negative (CPT)* coding guidance for reducing the bleeding from the pressure dressing is placed on trauma cases, including: “Coding stump of the leg. The surgeon the amputated leg stump. At the for damage-control surgery”† and arrives at the ED and performs end of the operation, the patient “Effectively using E/M codes for the primary and secondary is maintained on a ventilator trauma care.”‡ This article presents Advanced Trauma Life Support® with ongoing resuscitation and is several clinical scenarios involving (ATLS®) surveys, an abdominal transferred to the intensive care penetrating trauma and challenges and retroperitoneal focused unit (ICU). (See Table 2, page 47.) 46 | the reader’s coding knowledge assessment with sonography for for each example provided. trauma (FAST) exam, and exams Postoperative work in the ICU of the patient’s leg. The surgeon Later the same day in ICU, the orders administration of blood, surgeon examines the patient Trauma Scenario 1 antibiotics, and fluids based on and orders a blood transfusion, the examination, vital signs, and adjusts intravenous (IV) fluids Initial work in ED available labs. It is determined that to stabilize electrolytes/ A 25-year-old male involved in the partially severed leg, which coagulopathy, titrates the an accident related to a tractor’s was mangled by the tractor, is ventilator settings, and orders power take-off mechanism arrives unsalvageable. The surgeon pain medication. In addition, at the emergency department spent 30 minutes of critical care the surgeon needs to replace (ED) in shock with his right leg services in the ED before deciding the wound vacuum-assisted nearly amputated at the upper to go to the operating room closure (VAC) dressing, which (OR). (See Table 1, page 47.) has become dislodged. The *All specific references to CPT codes and surgeon spent 50 minutes descriptions are © 2017 American Medical Work in the OR total in the ICU; 30 minutes Association. All rights reserved. CPT and CodeManager are registered trademarks The patient is taken to the OR of critical care and 20 minutes of the American Medical Association. where the leg is removed and to replace the wound VAC. † Barney L, Jackson J, Mabry CD, all nonviable and contaminated (See Table 3, page 47.) Savarise M, Senkowski C. Coding for damage-control surgery. Bull Am Coll Surg. tissue is debrided. A total of 140 2013;98(8):57-61. Available at: bulletin.facs. sq cm of skin, muscle, and fascia org/2013/08/coding-for-damage-control- around the femur is excised Trauma Scenario 2 surgery/. Accessed January 30, 2018. ‡Jackson J, Mabry CD, Savarise M, and shortened to healthier Senkowski C. Effectively using E/M tissue. The femur is transected Initial work in the ED codes for trauma care. Bull Am Coll Surg. cleanly with a saw. Bleeding A 17-year-old male, involved 2013;98(6):56-65. Available at: bulletin. facs.org/2013/06/em-codes-for-trauma- is controlled with cautery and in an early morning bar fight, care/. Accessed January 30, 2018. ligation. After copious irrigation continued on page 49

V103 No 3 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

TRAUMA SCENARIO 1 TABLE 1. INITIAL WORK IN THE ED

CPT code(s) Total Relative Descriptor Global period to report Value Unit (RVU) Critical care, evaluation and management of the critically ill or critically 99291-57-25 XXX 6.35 injured patient; first 30–74 minutes Evaluation and management (E/M): The initial work in the ED included critical care and met the threshold of time to report 99291. In addition to describing the critical care work performed, it is advisable to document the start and stop time in the medical record. It is also advisable to confirm with any other providers (for example, ED physicians, other surgeons) that you were in charge of the critical care and you will be submitting 99291 for critical care management, since only one provider may report critical care services for a given period of time; that is to say that two or more providers cannot report critical care at the same time. Modifier 57, Decision for surgery, is appended. Modifier 25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, is also appended to indicate that this E/M service was separate and distinct from the 0-day global “minor” procedure code 11043, which is reported for wound debridement in the OR. CODING TIP: If a surgeon spends less than 30 minutes of critical care services in an ED before deciding to take a patient to the OR for surgery, an initial inpatient visit code (99221–99223) would be reported with modifier 57 appended for Medicare patients. For non- Medicare patients, when allowed, an inpatient consultation code (99251–99255) would be reported with modifier 57 appended.

TABLE 2. WORK IN THE OR

CPT code(s) Global Descriptor Total RVU to report period 27592 Amputation, thigh, through femur, any level; open, circular (guillotine) 090 19.65 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous 11043-51 000 4.47 tissue, if performed); first 20 sq cm or less Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous +11046 1.62 tissue, if performed); each additional 20 sq cm, or part thereof (List separately in ZZZ x 6 units | 47 addition to code for primary procedure) x 6 units Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound 97606-59 XXX 0.80 assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Amputation: Code 27592 is reported for the amputation of femur. Even though the wound is not closed, no modifier is required. Debridement: Codes 11043 (first 20 sq cm) and six units of add-on code 11046 (each additional 20 sq cm) are reported for debridement of the leg stump based on depth (fascia) and size (140 sq cm). The open fracture debridement codes (11010–11012) are not appropriate to report because an open fracture includes two pieces of bone that will be repaired and in this scenario there is no fracture, and only one piece of bone. Modifier 51, Multiple procedures, is appended to 11043 if required by the payor. Modifier 51 is never appended to add-on codes (for example, 11046). VAC: Code 97606 is reported for placement of the negative pressure wound therapy dressing and wound VAC, based on the surface area of the wound (80 sq cm). Modifier 59 is appended to indicate it is a service that is distinct from 27592. In addition, documentation should be clear that the wound VAC was medically necessary because the wound was left open.

TABLE 3. POSTOPERATIVE WORK IN THE ICU

CPT code(s) Descriptor Global period Total RVU to report Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound 97606-XE XXX 0.80 assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Wound VAC: Report code 97606 for replacing the negative pressure wound therapy dressing later in the day in the ICU and append modifier XE, Separate encounter, to distinguish this service from the work performed earlier in the day in the OR. If the wound VAC were replaced on a subsequent date, then modifier 58 (staged procedure) would be appended to 97606. No additional E/M code would be reported for postoperative work. Critical care codes 99291 and 99292 are reported for total time on a given date and not for each patient encounter. The 30 minutes of critical care before surgery plus the 30 minutes postoperative on the same date equal 60 total minutes and are reported with one unit of 99291 for the day.

MAR 2018 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

TRAUMA SCENARIO 2 TABLE 4. INITIAL WORK IN THE ED

CPT code(s) Descriptor Global period Total RVU to report 99221-99223-57-25 Initial hospital care or or 99231-99233-57-25 Subsequent hospital care XXX varies or or 99251-99255-57-25 Inpatient consultation Tube thoracostomy, includes connection to drainage system 32551-59 000 4.54 (eg, water seal), when performed, open (separate procedure) E/M: Although the patient has a high probability of imminent or life-threatening deterioration, code 99291 for critical care may not be reported because the surgeon’s total time in the ED minus time to insert the chest tube was less than 30 minutes (40 minutes minus 20 minutes). Instead, an initial hospital care code (99221–99223) for Medicare patients or inpatient consultation code (99251–99255) for non-Medicare patients (when allowed) is reported—if all three required key components are met. If all three key components are not met, then a subsequent hospital care code (99231–99233) is reported. No matter which E/M code is reported, modifier 57 is appended. In addition, modifier 25, Significant and separately identifiable E/M service, would also be appended because code 32551 has a 0-day global period. Modifier 25 indicates that the E/M service on the same date was not directly related to the “minor” 0-day global procedure. Chest tube: Code 32551 is reported for placement of the chest tube. When multiple procedures are reported, it is important to check Medicare’s National Correct Coding Initiative (NCCI) edits for code pairs that may be bundled and require a modifier to bypass the payment edit. Modifier 59 is appended to indicate that the chest tube placement is a separate and distinct service from the thoracoscopy procedure that is performed later in the OR on the same date. Because modifier 59 is appended, you do not also append modifier 51 to 32551.

TABLE 5. WORK IN THE OR 48 | CPT code(s) Descriptor Global period Total RVU to report Management of liver hemorrhage; simple suture of liver 47350 090 39.64 wound or injury Gastrorrhaphy, suture of perforated duodenal or gastric 43840-51 090 39.37 ulcer, wound, or injury 39501-51 Repair, laceration of diaphragm, any approach 090 24.56 Thoracoscopy, diagnostic (separate procedure); lungs, 32601-51 pericardial sac, mediastinal or pleural space, without 000 8.92 biopsy Procedures: Code 47350 (liver repair) would be reported first since it has the highest total work RVU, followed by codes 43840 (stomach repair), 39501 (diaphragm repair), and 32601 (thoracoscopy), respectively. If required by the payor, modifier 51 should be appended to 43840, 39501, and 32601.

TABLE 6. POSTOPERATIVE WORK IN THE ICU

CPT code(s) Descriptor Global period Total RVU to report No E/M code would be reported because the postoperative work to evaluate the patient at the patient’s bedside and in the ICU unit does not meet the requirement for reporting a separately identifiable E/M service. It is important to note that an E/M code (99291 or 99231–99233) is not billable for postoperative care related to the surgery. For example, managing an infection at the incision site or managing a bleeder left during surgery at bedside are related to the surgery and not billed as an E/M or critical care. On the other hand, volume issues, septic shock, acute respiratory distress syndrome (ARDS), managing other injuries that were not surgically treated and any clinical issues resulting from the injury—not the surgery—are separately reported with an E/M code and modifier 24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period, appended. There should be a diagnosis for separately identified problem(s) and the critical care time or level of E/M should be only that associated with the unrelated problem.

V103 No 3 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

sustained a single stab wound to performed with negative findings 20 minutes in the ED before the left chest in the mid-axillary for blood or other injury. The making the decision to go to line, just below the level of the diaphragmatic laceration the OR. (See Table 7, page 50.) nipple. He arrives at the hospital is closed via the abdominal awake and alert. The surgeon exposure and the abdomen is Work in the OR performs the ATLS primary and closed in standard fashion. The The patient is taken to the OR, secondary surveys and notes that patient is transferred to the where a midline laparotomy is the patient’s airway is patent, but ICU. (See Table 5, page 48.) performed. No significant intra- he has decreased breath sounds at abdominal injuries are found the left base. A chest X ray shows Postoperative work in the ICU other than a hematoma of the left-sided hemopneumothorax, Later the same day, the left flank and body wall. His left and the surgeon places a chest surgeon spends an additional colon is partially mobilized and tube. At this point, the patient 40 minutes with the patient the hematoma is explored and complains of a new subscapular and on reviewing progress no organ injury is found. The pain. Because intra-abdominal notes and interval labs, laparotomy wound is closed in | 49 injuries are suspected, the patient checking the wounds, routine fashion. Attention is is taken to the OR. The surgeon adjusting pain medication turned once again to the stab spends 40 minutes in the ED, orders, and documenting the wound which is expanded, including 20 minutes inserting a visit. (See Table 6, page 48.) probed, and debrided. Several chest tube before deciding to go bleeding vessels are sutured to the OR. (See Table 4, page 48.) and cauterized followed by Trauma Scenario 3 closure of the wound after Work in the OR hemostasis is obtained. The The patient is taken to the OR Initial work in the ED patient is transferred to the for a laparoscopic exploration. A 24-year-old male arrives in ICU. (See Table 8, page 50.) A defect in the diaphragm is the ED with a three-inch gash identified and blood clots are and stab wound to his left flank Postoperative work in the ICU noted on the anterior surface in the area of his spleen. The The surgeon spends an additional of the stomach and the left surgeon arrives in the ED and 20 minutes with the patient and in lateral segment of the liver. The performs the ATLS primary the ICU later in the day reviewing operation is converted to an and secondary surveys and an progress notes and interval labs, open laparotomy. Upon open abdominal and retroperitoneal checking the patient’s wounds, exploration, there are three Focused Assessment With adjusting pain medication lacerations on the surface of the Sonography for Trauma (FAST) orders, and documenting the liver that require suture closure. exam. His blood pressure is 90/50 visit. (See Table 9, page 50.) There is also a 2 cm perforation and although he is transiently of the anterior surface of the responsive to blood transfusions, stomach that is closed primarily blood continues to drain out of Learn more in two layers. To assess the the stab wound. The surgeon Learn more about trauma and extent of intra-thoracic injuries feels that emergent exploration general surgery coding at an more closely, a thoracoscopy is is indicated. The surgeon spends American College of Surgeons

MAR 2018 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

TRAUMA SCENARIO 3 TABLE 7. INITIAL WORK IN THE ED

CPT code(s) Descriptor Global period Total RVU to report 99221-99223-57-25 Initial hospital care or or 99231-99233-57-25 Subsequent hospital care XXX varies or or 99251-99255-57-25 Inpatient consultation Initial hospital care E/M: Similar to Scenario 2, code 99291 for critical care may not be reported because the surgeon’s total time in the ED was less than 30 minutes. Instead, an initial hospital care code (99221–99223) for Medicare patients or inpatient consultation code (99251–99255) for non-Medicare patients (when allowed) is reported—if all three required key components are met. If all three key components are not met, then a subsequent hospital care code (99231–99233) is reported. No matter which E/M code is reported, modifier 57 is appended. In addition, modifier 25 would also be appended because code 20102 has a 10-day global period. Modifier 25 indicates that the E/M service on the same date was not directly related to the “minor” 10-day global procedure.

TABLE 8. WORK IN THE OR

CPT code(s) Descriptor Global period Total RVU to report Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) 49000 090 22.27 (separate procedure) Exploration of penetrating wound (separate procedure); abdomen/flank/ 20102-59 010 7.38 back 50 | Abdominal exploration: An exploratory laparotomy and retroperitoneal exploration may both be performed through a midline incision. Code 49010, Exploration, retroperitoneal area with or without biopsy(s) (separate procedure), would only apply (instead of code 49000) if the major procedural initial intent was to explore the retroperitoneum. In this patient’s case, however, the retroperitoneal exploration was minimal and performed after no intraabdominal blood or injuries were found. Therefore, it is appropriate to report 49000. Wound exploration: Code 20102 is reported for exploring the penetrating stab wound to the left flank. Modifier 59 should be appended to 20102 to indicate work at a site that is distinct from the exploratory laparotomy.

TABLE 9. POSTOPERATIVE WORK IN THE ICU

General Surgery Coding reference with checklists, • Chicago, IL, November 1–3§ Workshop. By attending a coding resource guides, templates, and workshop, you will learn how to examples. Physicians receive up to At the May and November report surgical procedures and 6.5 AMA PRA Category 1 Credits™ workshops, a third day is added medical services and will have for each day of participation. that is devoted to trauma and access to the tools necessary The ACS will offer the critical care coding. More to succeed, including a coding following workshops in 2018: information about the 2018 ACS workbook to keep for future coding workshops is on the ACS • Chicago, IL, April 12–13 website at facs.org/advocacy/ § §These workshops offer a third day with a • New York, NY, May 17–19 practmanagement/workshops. ♦ focus on trauma and critical care coding. • Nashville, TN, August 9–10

V103 No 3 BULLETIN American College of Surgeons