Nirali H. Patel, MD
Pediatric Emergency Medicine
Children’s Hospital Medical Center of Akron
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4
1
3
1
2
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Total: 11 Years of Medical Experience
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years of Medical School
year of Research
years of Pediatric Residency
year of Pediatric Chief Resident
years of Pediatric Emergency Fellowship
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Estimate 80 hours work week (conservative!)
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80 hrs x 52 weeks/yr x 11 yr
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45,760 hours
A: 0-10 hours
B: 11-20 hours
C: 21-30 hours
D: 31-40 hours
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Article published May 2010 in Western
Journal of Emergency Medicine
◦ Surveyed 34 EM residents and 22 EM attendings
regarding overall comfort of billing and coding
◦ 91% of Residents and 95% of Attendings felt that
their jobs will require knowledge in billing & coding
◦ Only 26% and 29% felt they had adequate education
in billing and documentation during residency
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According to a 2004 Article in Emergency
Medicine Clinics of North America, surgical
and diagnostic procedures performed in the
ED are considered separate services for
coding purposes.
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A billable service is one listed in the CPT
manual that is performed as described.
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Includes orthopaedic procedures, laceration
repairs, foreign body removals, CPR.
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Uses
Support and protect injured bones and soft tissue.
Reduce pain, swelling, and muscle spasm.
Decrease movement
Provide support and comfort through stabilization
of an injury.
◦ Secure nonemergent injuries to bones until they can
be evaluated by orthopaedics.
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Advantages & Disadvantages
◦ Unlike casts, splints are noncircumferential and
often preferred in the emergency department
setting, since injuries are often acute and continued
swelling can occur.
◦ Splints or "half-casts" provide less support than
casts. However, splints can be adjusted to
accommodate swelling from injuries easier than
enclosed casts.
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Methods
◦ Custom Made: especially if an exact fit is
necessary.
◦ Ready-made splint:
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Off-the-shelf splints
Variety of shapes and sizes
Easier and faster to use
Easy to adjust, and to put on and take off due to velcro
straps
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Finger Splints
Thumb Spica Splint
Volar Splint
Dorsal Splint
Teardrop Splint
Boxer Splint
Reverse Sugar Tong
Elbow Splint
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Knee Immobilizer
Ankle Stirrup
Posterior Ankle
Posterior Leg
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Laceration coding depends on three variables
◦ Repair complexity
◦ Wound location
◦ Wound size
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CPT groups laceration repairs broadly into
three categories, by extent of repair.
◦ Simple
◦ Intermediate
◦ Complex
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Simple (singlelayer) repairs
(12001-12018,
APC 0133) involve
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Epidermis
Dermis
Subcutaneous Tissue
No signifiant
involvement of
deeper tissue.
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Intermediate repairs (12031-12057, APCs 0133
and 0134) involve
◦ Deeper layers
 Subcutaneous tissue
 Superficial (non-muscle) fascia
 Skin (epidermal and dermal) closure.
◦ Layered closure.
◦ Heavily contaminated wounds requiring extensive
cleaning may qualify as an intermediate repair, even if
single layer sutures.
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Complex repairs (13100-13153, APCs 0134 and
0135)
◦ Involve more than layered closure
 Extensive undermining
 Stents
 Retention sutures
◦ Extensive revision or repair of traumatic lacerations
◦ Avulsions
◦ Reconstructive or creation of a defect to be repaired
(scar excision with subsequent closure).
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Within each level of repair, CPT categorizes
wounds by anatomic location.
For example, simple repair codes 1200112007 apply to wounds of the neck, axillae,
external genitalia, trunk, and/or extremities
(including hands and feet).
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Determine code choice according to repair
complexity and anatomic location for each
wound
Then select final code according to the size of
the repaired wound(s).
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Multiple Wounds
◦ CPT treats all repairs of the same severity and
within the same anatomic classification as a single,
“cumulative” wound
◦ Choose one code only to describe two or more
repairs of the same severity in the same anatomic
category.
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Example
◦ Surgeon repairs lacerations on both hands (3 cm and 5 cm) and
the left arm (9 cm).
◦ All repairs qualify as intermediate because the physician must
remove particulate matter from the wounds, in addition to simple
closure.
◦ To report repair of the hand wounds, add together the individual
3-cm and 5-cm lacerations for a total size of 8 cm
◦ Report 12044: Repair, intermediate, wounds of neck, hands, feet
and/or external genitalia; 7.6 cm to 12 cm
◦ For the arm wound, select 12034 Repair, intermediate, wounds of
scalp, axillae, trunk and/or extremities [excluding hands and
feet]; 7.6 cm to 12.5 cm
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Traumas or Cardio respiratory Arrests
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Chaotic Documentation
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Includes
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Intubations
Central Lines
Intraosseous Lines
Thoracocentesis and Thoracotomy Tubes
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In the ED, will not
be an elective
intubation.
Emergent
intubation usually
preceded by Rapid
Sequence
Intubation (RSI)
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Endotracheal intubation, emergency (CPT 31500)
◦ Use this code in emergency or crisis situations, not for
elective intubation
◦ Documentation should support an emergent need
through appropriate coding
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Critical care codes
◦ Intubations are considered separately billable
procedures from critical care services
◦ Must subtract the time you spend on these procedures
from the time you bill for critical care services
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Multiple Sites
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Requires Sterile Site
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Associated with
more risks and
complications
Usually requires a
specialist
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When IV access
has failed
Does not require
sterilization or
specialist
Used to rapidly
obtain access
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Used for air in the
lungs causing
difficulty
breathing
(Tension
Pneumothorax)
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For blood or fluid in
the lungs or lung lining
(hemothorax, pleural
effusion) or large
pneumothorax
Sterile procedure
May be done under
conscious sedation in
stable patients or while
patient is intubated
during resuscitation