Emergency Room Procedures

1. Emergency Room Procedures Nirali H. Patel, MD Pediatric Emergency Medicine Children’s Hospital Medical Center of Akron

2. 4 years of Medical School 1 year of Research 3 years of Pediatric Residency 1 year of Pediatric Chief Resident 2 years of Pediatric Emergency Fellowship Total: 11 Years of Medical Experience My Background

3. Estimate 80 hours work week (conservative!) 80 hrs x 52 weeks/yr x 11 yr 45,760 hours Converted into Hours

4. A: 0-10 hours B: 11-20 hours C: 21-30 hours D: 31-40 hours Hours Spent on Learning Billing and Coding?

5. 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 Docs Are Not Comfortable With Billing & Coding…so be patient!

6. 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. A billable service is one listed in the CPT manual that is performed as described. Includes orthopaedic procedures, laceration repairs, foreign body removals, CPR. Surgical & Diagnostic Procedures in the ER

7. 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.  Orthopaedic Procedures in the ED: Splinting

8. 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. Orthopaedic Procedures in the ED: Splinting

9. Methods Custom Made: especially if an exact fit is necessary. Ready-made splint: 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 Orthopaedic Procedures in the ED: Splinting

10. Finger Splints Thumb Spica Splint Volar Splint Dorsal Splint Teardrop Splint Boxer Splint Reverse Sugar Tong Elbow Splint Upper Extremities Splints

11. Knee Immobilizer Ankle Stirrup Posterior Ankle Posterior Leg Lower Extremity Splints

12. Laceration coding depends on three variables Repair complexity Wound location Wound size Laceration Repairs in ED

13. CPT groups laceration repairs broadly into three categories, by extent of repair. Simple Intermediate Complex Laceration Repairs in the ED: Wound Complexity

14. Simple (single-layer) repairs (12001-12018, APC 0133) involve Epidermis Dermis Subcutaneous Tissue No signifiant involvement of deeper tissue. Laceration Repairs in the ED: Wound Complexity

15. 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. Laceration Repairs in the ED: Wound Complexity

16. Laceration Repairs in the ED: Wound Complexity

17. 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). Laceration Repairs in the ED: Wound Complexity

18. Laceration Repair in the ED: Wound Complexity

19. Within each level of repair, CPT categorizes wounds by anatomic location. For example, simple repair codes 12001-12007 apply to wounds of the neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet). Laceration Repairs in the ED: Location

20. 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). Laceration Repair in the ED: Wound Size

21. 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. Laceration Repair in the ED: Wound Size

22. 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 Laceration Repair in the ED: Wound Size

23. Traumas or Cardio respiratory Arrests Chaotic Documentation Includes Intubations Central Lines Intraosseous Lines Thoracocentesis and Thoracotomy Tubes Resuscitation in the ED

24. In the ED, will not be an elective intubation. Emergent intubation usually preceded by Rapid Sequence Intubation (RSI) Resuscitation in the ED: Intubation

25. 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 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 Resuscitation in the ED: Intubation

26. Multiple Sites Requires Sterile Site Associated with more risks and complications Usually requires a specialist Resuscitation in the ED: Central Lines

27. When IV access has failed Does not require sterilization or specialist Used to rapidly obtain access Resuscitation in the ED: Intraosseous Line

28. Used for air in the lungs causing difficulty breathing (Tension Pneumothorax) Resuscitation in the ED: Needle Thoracotomy

29. 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 Chest Tube

30. Chest Tube