In Emergency Department, we have seen the importance of procedures or exams performed on the patients. Missing these procedures seriously affects the payment or reimbursement. Many immature coders are not aware of the documentation of these exam in emergency department report and missed to code them. Previously we have seen how we can report a short leg splint in a emergency department report and the supporting documentation required for it. Today we will checkout the coding of simple repair with emergency department cpt codes.
The repair procedures are performed generally when a patient has a laceration or wound and comes for an ED visit. These procedures are simple to code and has direct codes in CPT code book.
Unlike infusion/injection/hydration, the procedures codes are little easy to code in emergency department. Documentation is very important for coding each and every procedure in emergency department.
Sample Coded Simple Repair Procedure in Emergency Department (ED) report
Chief Complaint & History of Present Illness :
CC: Laceration to right index finger
25 year old Left handed male presents to laceration to right index finger while cutting a bagel at 9:30 this morning. unknown last tetanus vaccination.He denies any medical problems or daily medication
Past Medical History :
# PMH: none reported
Primary MD:
Old records: Medications: none
Allergies
No Known Drug Allergies
Home Medications
cephALEXin, 500 milligram orally every 6 hours (Duration: 10 days)
Immunizations
Tdap – 115
Social History
nonsmoker, admits to alcohol consumption
Review Of Systems
ROS:
IX] All systems reviewed and found to be negative except those mentioned in the history of present illness.
Vital Signs
Most Recent Set of Vitals:
BP: 147/90 08/15/2019 11:44
Pulse: 62 08/15/2019 11:44
Temp: 36.5 C 08/15/2019 10:04
Resp: 16 08/15/2019 10:04
02 Sat: 100%(Room Air) 08/15/2019 11:44
Calculated BMI: 25.5 08/15/2019 10:04
Additional Vitals:
TRIAGE:
Temp 36.5 C 08/15 10:04
BP 1 126/65 08/15 10:04
Pulse 68 08/15 10:04
Resp 16 08/15 10:04
02 Sat%,PulseOx 98% Room Air 08/15 10:04
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 98 % Interpretation: Normal Date/Time:
Physical Exam
# GENERAL
General: Awake, alert, oriented x3, cooperative, and in no apparent distress.
Head: Normocephalic and atraumatic.
Pulmonary: Clear to auscultation bilaterally, no respiratory distress.
Cardiac: Regular rate and rhythm, no murmurs rubs or gallops.
Musculoskeletal: 2cm laceration to oblique distal to pip joint on volar surface right index finger.FDS tendon intact.
FDP tendon not functional.No bony deformity.Range of motion normal at the joints.Peripheral pulses intact,
Capillary refill brisk at finger tip.
Neurologic: Moves all extremities normally With 5/5 strength throughout, sensation intact throughout to light touch,
two-point discrimination intact laterally and medially on affected finger.Gait normaL speech and coordination normaL
Skin: Laceration, as noted above. no obvious foreign body.
Progress Notes:
Spoke to Dr. , plastic surgeon on duty about patient.He requests that the laceration be irrigated and approximated, and that the patient be started on prophylactic antibiotics.He will see the patient in his office and arrange for Tendon repair.
Progress [This section may be copied as needed]
Date / Time: 08/15 1120
Condition: Improved
Progress Notes:
Procedure: Laceration repair, 2 cm, right index finger, Simple.
informed consent was obtained from the patient verbally.Local anesthesia was achieved by infiltration of 1% Buffered lidocaine x2 mL, with good result.Wound was irrigated with copious normal saline under pressure.Wound was explored.No deep structures were noted to be involved.No foreign body was notable wound.Wound was approximated with 5-0 nylon interrupted x3 sutures, with good approximation and hemostasis.Antibacterial ointment and sterile dressing were applied. metal splint applied.Patient tolerated the procedure well.No complications.
Medical Decision Making (MDM) :
Patient presents with laceration on the volar right index finger, and findings are consistent with FDP tendon laceration.Plastic surgeon was consulted, he requests that the wound be closed, and he will follow up for repair the tendon in his office.No further measures required at this time.
Differential diagnosis includes digital nerve injury, arterial compromise, foreign body, secondary infection, I do not believe any above was present.The patient does have evidence of a tendon laceration.Diagnoses considered not limited to those discussed here.
Plan: The wound repaired as above.Wound splinted.Keflex 500 mg p.o. q.i.d., 1st dose given in the ED.Go to Dr. office now To arrange further care.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Laceration of index finger None Associated Active 2019
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
Condition at D/C: Stable
CPT codes:
99283
12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.5 cm or less
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