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Test Your CPT Coding Knowledge for Penetrating Trauma

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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.
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