Coder's Corner

by R. Lawrence Reed III, MD, FACS, FCCM & Thomas Esposito, MD, MPH

During a day on trauma call, you respond to a trauma activation in which a 76-year-old female was struck by an automobile at low speed. She is obtunded with a GCS of 10, but hemodynamically unremarkable on arrival. Endotracheal intubation is performed, and secondary assessment is notable for a right lower extremity deformity. The patient has an isolated low systolic blood pressure reading during assessment and a FAST exam with free fluid in the abdomen (but notably, a negative pericardial view), so she is taken to the OR for exploratory laparotomy.

On exploration, she has a minimal amount of hemoperitoneum, but an actively hemorrhaging splenic laceration, so a splenectomy is performed. In spite of apparent hemorrhage control, the patient now has ongoing hypotension, and the pericardial window is completed, which is positive. Median sternotomy is performed, and on completion of the pericardotomy, the patient is noted to have a right ventricular free wall rupture. A second surgeon is called in to assist, as the patient’s attenuated right ventricular wall fails to hold pledgeted sutures. Ultimately, after multiple attempts, the defect is repaired and hemostasis is obtained. At this point, the patient is hypothermic, and in addition, a thoracoabdominal-negative-pressure wound dressing is fashioned from x-ray cassette covers, gauze, suction tubing, and ioban, which is applied from sternal notch to pubic tubercle prior to transporting the patient to the intensive care unit.

Questions:

1. How should this case be coded?

2. What documentation is necessary to account for the difficulty encountered during the right ventricular repair?

3. Is there a code beyond just Negative Pressure Wound Therapy > 50 cm² (97606) for a VAC-type dressing that spans the entire torso?

Esposito:

We would code this case as follows:

99291 (4.5 wRVUs) for initial critical care with a 57 modifier since there was a decision to go to surgery. We would also add a 59 modifier to denote that this is a separate service from the intubation and FAST. Documentation should state the amount of critical care time separate from intubation.

31500 (3.00 wRVUs) for the intubation. An intubation procedure note should be documented and should include details of the procedure as well as the time spent doing the procedure. Again, this should be noted separately from other critical care.

76700 (0.81 wRVUs) for the FAST. FAST is not bundled with 99291 and therefore does not require a 59 modifier. Image documentation is required.

In the OR:

38100 (19.55 wRVUs) for the splenectomy. A 59 modifier should be added, as this is a separate procedure.

33025 (13.7 wRVUs) for the pericardial window. This is not bundled with cardiac repair, so a 59 modifier is not necessary.

33300 (44.97 wRVUs) for the cardiac repair. Because it was difficult, it merits a 22 modifier with proper documentation in the op note of the procedure—all taking more effort and expertise than usual. That would include: the fact that the ventricle wall was attenuated, the failure of the tissues to hold pledgeted sutures, the number of multiple attempts, as well as the additional time spent trying to do the repair and the need to call in help. The 22 modifier does not increase RVUs—it only increases the procedural charge.

We don't know of any codes or modifiers that would account for the VAC spanning both abdomen and chest and therefore would code 97606 (0.6 wRVUs) once. A 59 modifier is not necessary. 

As far as the other surgeon, he or she should bill separately for the cardiac repair (33300) with an 82 modifier. A separate op note by that surgeon is not necessary. However, there must be documentation in the primary surgeon's note that there was no qualified resident available to help and that the complexity warranted the presence of another attending.

Reed:

There are two documentation requirements for billing the critical care charge (99291):

1. The patient must meet the criteria for having critical illness and
2. The amount of time spent providing critical care, exclusive of the time spent on procedures, must be documented.

Because of the neurologic obtundation, the respiratory care needs, and the hypotension, the patient meets the criteria for being critically ill. If you, the physician, spent at least 30 minutes in evaluating (i.e., primary & secondary survey) and managing (i.e., determining IV solutions of crystalloid and/or blood products and/or initiating the massive transfusion protocol, setting and adjusting ventilator settings, etc.) the care, then you can bill a 99291 for critical care. In doing so, you must document the conditions making the patient critically ill. So you should state in the critical care note:

"The patient is in critical condition requiring constant attention. I performed a primary survey, identifying that she is severely neurologically obtunded with a Glasgow Coma Scale score of 10. In order to ensure adequate ventilation and oxygenation as well as airway protection, I determined that she required endotracheal intubation. In addition, the patient's circulation is compromised as manifested by a hypotensive blood pressure. The patient's heart rate was higher than the patient's systolic blood pressure, indicating a Shock Index greater than 1. I therefore ensured that we established adequate intravenous access for fluid resuscitation, began the rapid infusion of crystalloid solutions, and initiated the massive transfusion protocol.

Also, because of the hypotension, I obtained a portable AP chest Xray and an AP pelvic Xray, and I performed an abdominal FAST exam—all looking for a source of internal hemorrhage to explain the hypotension. The FAST exam was positive, so I took the patient immediately to the operating room for hemorrhagic control. I also performed a quick secondary survey while in the Trauma Bay: I performed a head-to-toe and front-and-back physical examination of the patient. The secondary survey was grossly unremarkable except for the finding of a right lower extremity deformity; this will need imaging later. I spent a total of ___ minutes, exclusive of procedural time, in providing critical care to this patient."

Note that the documentation for critical care billing does NOT require the formal sections of History (including chief complaint, history of present illness, past medical, surgical, social, family histories; and review of system), Physical Examination (which must document multiple body areas), and Medical Decision Making of a certain degree of complexity. The critical care note can actually be a free-form note. It merely needs to establish the critical condition of the patient and outline the evaluation and management processes that you undertook. It also needs to document the time, in minutes, that you spent performing the critical care.

The potential problem with this situation is that, depending how efficient you are, this entire encounter in the initial resuscitation phase could take less than 30 minutes, especially if you exclude the time it took you to perform the procedures (i.e., the intubation, placement of intravenous lines, FAST exam, etc.). For example, if it takes you 5 minutes to intubate the patient, 10 minutes to get IV access, and 4 minutes to complete the FAST, the total procedural time is 19 minutes. If you are out of the Trauma Bay and on your way to the OR after 45 minutes of evaluation and procedures (which could be seen as a prolonged period by many), you can only claim 26 minutes of E&M time. Thus, you will not meet the 30-minute minimum threshold for billing the 99291 critical care charge.

In that case, you could bill a 9928x code for the Emergency Room visit; the "x" can range from 1–5 depending on the extensiveness and detail of the History and Physical exam note. The problem with this kind of note as opposed to the critical care note, is that the 9928x note does require the formal structure of History, Physical Examination, and Medical Decision. Here, your reimbursement is improved based primarily upon the level of detail provided in the note.

For example, the 99281 (lowest level charge) only requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making, so the documentation requirements are minimal: The problem-focused history requires a brief history of the present illness (HPI) only, documenting only one to three of the seven elements of the HPI (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms). The problem-focused examination requires only a limited examination of the affected body area or organ system. And, finally, straightforward decision-making only requires a minimal number of diagnoses or management options, minimal complexity of data (i.e., lab results, vital signs) to review, and minimal risk of complications and/or morbidity and mortality. However, the 99281 only provides 0.45 work RVUs and 0.60 total RVUs. In addition, such a charge would represent underbilling for this patient because of the very high complexity of the medical decision-making.

On the other hand, the 99285 provides 3.8 work RVUs and 4.89 total RVUs, which gets us closer to the 4.5 work RVUs and the 6.3 total RVUs you get with the 99291 charge. However, the documentation requirements for the 99285 are pretty onerous as it requires a comprehensive history (i.e., an extended HPI, a complete review of systems, as well as a complete past, family, and or social history), a comprehensive examination (i.e., a general multi-system examination, or a complete examination of a single-organ system and other symptomatic, or related, body areas or organ systems), and medical decision-making of high complexity (i.e., an extensive number of diagnoses and management options, an extensive amount and/or complexity of data to review, and a high risk of complications and/or morbidity or mortality). While the patient's evaluation and management could hit all of those high points because of the severity of her condition, it is certainly painful to document all of the above in a standard note structure.

How to bill the critical care note legitimately and avoid the headache of the more structured E&M note? Remember that the total critical care time spent with the patient includes the time spent in writing your note. So make sure you take the time to write a good, action-packed note that thoroughly covers all the bases of your evaluation and management of the patient. Note things like the patient's initial fluid responsiveness. Indicate whether she appeared to be a responder, transient responder, or non-responder. Note your plans for anticipated postoperative tasks, such as CT scans or extremity Xrays. And because the critical care charge comprises the total amount of time you spent in managing the patient during the day, you can also include any evaluation and management processes you undertook during and after the operation, thus meeting—and likely exceeding—the 30-minute minimum requirement for the 99291 charge. In fact, if you were at the patient's bedside postoperatively managing the patient's fluids, ventilator, etc., that should all be included in the 99291 time. If your critical-care E&M time now totals more than 75 minutes—which is likely the case—then you can start adding on multiples of 99292s, which cover each additional 30-minute increment of critical care time; there is a 15-minute minimum before each additional 99292, 30-minute charge can be applied. And remember, the time you spent writing the note is added to the actual evaluation and management time you provided the patient, in order to get the grand daily total of your critical-care time.

The other comment I would make is that if the assistant surgeon is another general or trauma surgeon, Dr. Esposito's assessment of the coding and documentation requirements is accurate. However, if the other surgeon is from another subspecialty, such as if he or she is a cardiothoracic surgeon, then both surgeons can bill the same CPT code, but you will each need to document your own operative report describing the portion of the procedure that you performed. In addition, you would each add a 62 modifier ("two surgeons") to the CPT code.