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

 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

 Estimate 80 hours work week (conservative!)  80 hrs x 52 weeks/yr x 11 yr  45,760 hours

A: 0-10 hours B: hours C: hours D: hours

 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

 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.

 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.

 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.

 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

 Finger Splints  Thumb Spica Splint  Volar Splint  Dorsal Splint  Teardrop Splint  Boxer Splint  Reverse Sugar Tong  Elbow Splint

 Knee Immobilizer  Ankle Stirrup  Posterior Ankle  Posterior Leg

 Laceration coding depends on three variables ◦ Repair complexity ◦ Wound location ◦ Wound size

 CPT groups laceration repairs broadly into three categories, by extent of repair. ◦ Simple ◦ Intermediate ◦ Complex

 Simple (single- layer) repairs ( , APC 0133) involve ◦ Epidermis ◦ Dermis ◦ Subcutaneous Tissue ◦ No signifiant involvement of deeper tissue.

 Intermediate repairs ( , 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.

 Complex repairs ( , 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).

 Within each level of repair, CPT categorizes wounds by anatomic location.  For example, simple repair codes apply to wounds of the neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet).

 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).

 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.

 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 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm

 Traumas or Cardio respiratory Arrests  Chaotic Documentation  Includes ◦ Intubations ◦ Central Lines ◦ Intraosseous Lines ◦ Thoracocentesis and Thoracotomy Tubes

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

 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

 Multiple Sites  Requires Sterile Site  Associated with more risks and complications  Usually requires a specialist

 When IV access has failed  Does not require sterilization or specialist  Used to rapidly obtain access

 Used for air in the lungs causing difficulty breathing (Tension Pneumothorax)

 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