Volume 3, #2

May 2006

In this issue:

• Fracture Care Coding: Documentation Supporting the Assignment of Definitive Care and Restorative Care
• Critical Care Documentation: The Underutilized Revenue Opportunity
• Simple versus Complex versus Complicated? What do these Terms have to do with Documentation and Reimbursement for Procedures Performed in the ED? Answer: Plenty!
• Coding Operations: New & Familiar Faces

Fracture Care Coding: Documentation Supporting the Assignment of Definitive Care and Restorative Care

Jeffery Wajda, DO, MS, FACEP
Vice President of Clinical Support Services

Many EP’s are not appropriately documenting the necessary and sufficient criteria allowing the assignment of Definitive non-manipulative care. If you are unfamiliar with this terminology, this primer will help you consistently achieve compensation reflecting the complexity of fracture care that you provide on a regular basis.

Emergency providers can ensure appropriate fracture care coding by clearly documenting the care in the ED and what care is expected to occur after the ED visit. A separately headed procedure note is strongly recommended titled “Fracture Treatment” or “Dislocation Treatment.” Coders are looking for the specific location of the fracture/dislocation, identification of the definitive fracture care needed and who will be providing the definitive care (i.e. ED provider or referral doctor). The following definitions and supporting information help to illustrate these points.

Definitive non-manipulative fracture and/or dislocation treatment is defined as treatment which is complete or is nearly complete and is the same care that a specialist would provide. Patient follow up may not be required.

Examples include fractures that are simple non-angulated, non-displaced fractures which are expected to heal well without the need for a subsequent surgical procedure. EP documentation should include:

• Ruling out neurovascular compromise or complications.
• Treatment plan including stabilizations and support, patient education, analgesia and follow-up instructions.

Proximal humerus fractures often qualify for definitive non-manipulative care. Also, elderly hip fracture patients not meeting criteria for surgery will often be treated conservatively with bed rest. These patients qualify for Definitive care in the ED. Many other examples apply.

Restorative fracture and/or dislocation treatment involves manipulation. Restorative care involves restoring a fracture or dislocation to its normal or significantly improved anatomical alignment. Most restorative ED care will require some level of follow-up care. Examples include shoulder and digit dislocations. Many other examples apply. Once again, the practitioner should document that neurovascular compromise is ruled out and that treatment plan/education was discussed and understood by the patient.

Comfort care should be documented when the criteria for Definitive or Restorative care is not satisfied.

You are entitled to the significant compensation resulting from ED Definitive and Restorative care. Appropriate documentation will insure that your coders can assign the code representing your definitive care. Our E/Map practitioner templates are designed with prompts helping assure documentation of the required clinical elements. Please contact your coding manager if questions arise regarding your groups documentation performance in this area. Also, look for feedback in the monthly coding reports.

Critical Care Documentation: The Underutilized Revenue Opportunity

Jeffery Wajda, DO, MS, FACEP
Vice President of Clinical Support Services

CPT Codes 99291 and 99292 (Critical Care) appropriately assigned based on care provided and satisfactory documentation can result in several hundred dollars in additional compensation when compared to a basic level 5 admit (code 99285). When reviewing Emergency Physician medical records one of the most frequently deficient documentation areas involves Critical Care. The following summary will help guide your precise critical care documentation during your next ED shift.

To qualify for assignment of critical care you must satisfy three CPT criteria:

1. Criticality.

   CPT defines critical care as the direct delivery by a physician(s) of medical care for a critically ill or injured patient. Critical Care services only apply if the illness or injury is organ or life threatening. Specifically, vital organ system failure of the CNS, circulatory system, renal, hepatic, metabolic or respiratory systems apply. Please note that there is no mention of stability. A patient does NOT have to have unstable vital signs to be considered for critical care.

2. Time.

   • Code 99291 (first 30-74 minutes of critical care)
   • Code 99292 (Each additional 30 minutes)

   A physician does have to ask for critical care and MUST document the time involved in direct delivery of care. There is no harm in asking for critical care. Documentation requirements for critical care are not as comprehensive as for level 5 assignments. If you are sure that the patient satisfies the three criteria for critical care, you are not required to document HPI, ROS or PFSH. If uncertain whether a patient encounter satisfies the definition for critical care, we recommend that you document for a level five charge.

   Time which qualifies as critical care time includes not only time at the bedside, but also:

   • Time engaged in patient care away from the bedside.
   • Consultation time, review of new diagnostic data and previous records.
   • Time spent with a family or surrogate decision makers when the patient is not competent to participate in discussions.

   Note: Time spent in non bundled procedures must be documented separately. Examples include intubation, and CPR. Bundled services included in critical care time include CXR interpretation, Blood draws, Interpretation of blood gasses, Interpretation of pulse oximitry, ventilator management, gastric intubation requiring physician involvement and vascular access.

3. Treatment/Interventions that were Life and Organ Supporting.

   Document all organ sustaining interventions that require physician assessment and intervention. If these interventions were not performed, acute deterioration of the patient’s condition could be expected. Examples include:

   • Thrombolytics
   • Anti-arrhythmics
   • Epinephrine, Atropine, Sodium Bicarbonate
   • Bi-PAP/C-PAP
   • Cardioversion for Atrial Fibrillation or Atrial Flutter
   • Defibrillation
   • Fluid and of Blood administration for shock or impending shock
   • Narcan
   • NTG drip
   • Intubation

   Note: Keep in mind that these examples must exist in conjunction with the patient meeting #1 above, the Criticality requirement.

Although not all patients requiring a lengthy workup qualify, attention paid to the three requirements above will result in documentation supporting the assignment of critical care codes. For more information, email us.

Simple versus Complex versus Complicated? What do these Terms have to do with Documentation and Reimbursement for Procedures Performed in the ED? Answer: Plenty!

Candace E. Shaeffer, RN, MBA, RHIA
Vice President of Coding Policy

Several ED procedure codes are differentiated by the terms simple, complex, or complicated. Most of these codes are for integumentary procedures and include services such as laceration repairs, I&Ds, incision and removal of foreign bodies, and foreign body removals from muscle or tendons. Other procedures include insertion of temporary indwelling bladder catheters and cystostomy tube changes. The complex and complicated codes have a higher RVU value, and thus higher reimbursement. Coders rely on detailed physician documentation in these circumstances to tell them how complex the service was and assist them in accurate code selection.

With the exception of wound repairs, CPT does not offer specific definitions of simple and complex or complicated for services when there is an option to choose one or the other. It is up to the physician or mid-level provider, to decide if the amount of work or effort and the service is simple and straightforward or more time-consuming, complex, and complicated. The clinician must document specific information about the patient’s condition and/or the procedural service so the coder can determine if a simple or complicated/complex service code is correct. Best practice documentation for these procedures includes:

• A description of the lesion with notation indicating its size in centimeters (cm), if it is deep or more superficial, if single or multiple (with numbers) and if it contains a significant amount of exudate. Any work performed on the lesion should be described in detail.

• For I&Ds, notation of any blunt dissection to open individual pockets and specific information about any packing or insertion of drains.

• Notation when a foreign body was removed from a muscle or tendon re: how deep and/or complex the procedure was.

• A detailed description of any exploration or enlargement of a wound, debridement, ligation or coagulation of blood vessels, and repairs to structures.

• For wound repairs—the exact location(s) and length of the repaired wound(s) in cm; the layers of tissue affected; the degree of contamination, extent of cleaning and/or debridement; and any undermining, stents, or retention sutures placed.

• For urinary system procedures notation of the degree of difficulty and any complications such as altered anatomy or a fractured catheter/balloon. Documentation should include presence or absence of bleeding, blood clots, the need for irrigation and the method by which it was performed, and any other factors that demonstrate procedural complexity.

Coding Operations: New & Familiar Faces

Shannon Weintraub, MBA
Director of Coding Operations/QM

Each year brings growth and change. As a result, we have added additional personnel to better serve your needs. This is an opportune time to introduce you to the new and reacquaint you with those that you’ve come to depend upon:

Coding Operations

New :: Steve Reinhart — Comes to LYNX with over 20 years of healthcare experience, with the last 9 years in various management positions. His undergraduate degree is in Music Therapy, which he practiced until earning his Masters Degree in Management from Cardinal Stritch College. His background includes managing Outpatient Mental Health Services, Residential Mental Health Services and a Family Physician practice in the Seattle area.

Kevin Weber — Kevin joined LYNX in March of 2005. He brings more than 6 years of Emergency Medicine/Healthcare knowledge acquired while working for the United States Navy. He currently holds an AA in Health Science Technology, and a BS in Healthcare Management and Administration from Southern Illinois University at Carbondale.

Michael Gaeta, MBA — Mike joined LYNX in February 2005. He brings with him a 10 year history of working in the medical field as a podiatric physician in hospital, military and private practice settings. After completing his MBA studies, he worked in business development for a startup e-fulfillment company.

Stacy Land — Stacy has been with LYNX for more than three years, functioning in the role of coding operations manager and most recently as special project manager. She has past experience as a practice manager and consultant for individual medical practices, including the creation of two new clinics.

Laura Bennett, RHIT — Laura has worked at LYNX for more than 7 years, most currently in the role of coding operations manager. She has taught both coder and physician education classes, managed our QM Department and has worked with our Coding Review Services (CRS) Clients as client manager.

Sally Strand, RN — Sally has been with LYNX for 16 years, working from our regional office in Tampa, Florida. She brings a clinical background in the Emergency Department, coding expertise and a solid foundation for providing consistently outstanding service to her clients.

Gary McClanahan – Gary has been with LYNX since 2004. He has a clinical background in Emergency Medicine as a EMT/Paramedic. Gary earned an MA in Education from the University of Missouri. He brings with him nearly 30 years of both clinical and management experience.

Client Services

New :: Mark Epperson — Mark comes with over 20 years of account and relationship management experience. Most recently, he worked as a national account manager servicing a number of prestigous nationwide accounts. He also acquired experience managing a payroll team as a payroll account manager, as well as time spent on both major and nationwide accounts. He started his business career as a territory manager in Southern and Northern California, and the Pacific Northwest.

Kathe Newell — Kathe has acquired more than 20 years of healthcare experience with both payers and providers. Her expertise includes reimbursement, information systems, quality improvement, account and client management. Her current role at LYNX leverages these skills as client manager for both coding and software clients.

Suzanne Bingham — Suzanne comes to LYNX with 25 years of healthcare experience. She began her career in healthcare as a programmer for an international pharmaceutical corporation where she designed and programmed clinical trial outcomes analysis. She has also worked for several established health information system companies as an account executive and/or client manager. She holds a bachelor’s degree in English.