Coding to New Heights Education Newsletter June 2019 Edition

Peak Health Solutions - Jun 14, 2019


Welcome to our Monthly Peak Coding Education Newsletter, June 2019 Edition! This month we'll discuss: ICD-10-CM – Coding Head Injuries, ICD-10-PCS – Root Operations for Fracture Repair, CPT – Understanding Burn Treatment Procedures, Pro-Fee – Critical Care Codes, Anatomy Feature – Anatomy of Coding Open Gustilo Fractures, CDI Corner – Documentation Nuggets in ER Record, Pharmacology Spotlight – Lasix®

In This Issue


Funny Documentation Fail

“Patient was alert and unresponsive"



Coding Head Injuries

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

When coding head injuries in ICD-10 the coder must determine what type of injury occurred by meticulously reading documentation from ER reports, trauma reports, radiology reports, and possibly even EMS run sheets. The questions we seek answers to are: Was there a fracture and if so, what bones were involved and were any open? Were there intracranial brain injuries, or cranial nerve injuries? Are there scalp lacerations that were sutured, Are there contusions and if so where? Was there a concussion? Was there loss of consciousness and is the documentation of that consistent? This may seem like a lot of questions but for a coder these all fly through our brains in a split second as we scan documentation noting our findings. Once we locate the overall injury, we drill down for the nitty gritty details all the while applying official coding guidance.

The nitty gritty I speak of is broadly categorized into the following four areas: superficial contusions and abrasions, cranial nerve injuries, skull and facial bone fractures, and loss of consciousness.

Superficial Contusions and Abrasions
Official guidance here tells us to code each superficial injury unless it is associated with a more severe injury of the same site. Many coders wonder if they have to choose which to code if an abrasion and a contusion are at the same site. To date there is no rule that we can’t. Generating a hospital specific policy on how to deal with this situation can help. Coding every superficial injury may take much of the coders time and the codes most likely will not impact the DRG or SOI/ROM.

Injury to cranial nerves
Guidance here tells us when a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is listed first followed by codes for the nerve and blood vessel injuries. The exception being when the nerve or blood vessel injury is the primary injury and then, of course, it would be listed first.


Skull and Facial Bone Fractures

Skull and facial bone fractures are classified to the S02 category. With additional detail of location, type, and laterality. Multiple fractures are sequenced in accordance with the most severe being listed first. If this can’t be determined a query to the provider should be generated. Each fracture site is coded individually to the level of detail furnished by the documentation and available within the coding convention. When documentation is lacking or not available, we are directed in the following manner: If the fracture is not stated as open or closed the default is closed; If details of displaced or nondisplaced is not available code to displaced.

When coding fractures of the skull or face we are directed by a “code also” note telling us to code additionally any associated intracranial injury. These would be injuries such as contusion, laceration, or hemorrhage of the brain. Fractures that involve multiple bones of the mid face are called Le Fort fractures. This type of fracture is categorized into three types depending on which bones are involved. See diagram above. Be sure to read radiology reports and other documentation very carefully to see if the type was specified.

Loss of Consciousness
One major detail to contend with when coding head injuries is determining the level of consciousness. Loss of consciousness or LOC is a component of codes for concussion, cerebral edema, diffuse (widespread) brain injury, focal (specific area) brain injury, contusion and laceration, and intracerebral hemorrhage. In ICD-10 LOC is designated by the time the patient was unconscious: 30 min or less, 31-59 min, 1 hour to 5 hours 59 min, 6-24 hours, greater than 24 with return to pre-existing conscious level, greater than 24 hours without return, not regained with death due to brain injury or not regained with death due to other injury. Careful review of the emergency room documentation and admitting notes may contain this very necessary information.

In conclusion; a general coding rule when coding injuries is that each injury is coded separately unless the convention has a combination code. The code T07 multiple injuries is not to be assigned on inpatients unless more detailed information is not available. Sequencing rules for injuries are to code the more serious injury first. This should be determined by the provider and supported by the focus of treatment.




Root Operations for Fracture Repair

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

The official coding guidelines for PCS tell us that reduction of a fracture is coded to the root operation Reposition and if a cast or splint is applied in conjunction, it is not coded separately. If we are dealing with a fracture that doesn’t require reduction, we could be looking at external fixation or casting. The placement of a pin (Steinmann pin) or wire (Kirschner wire) is coded to the root operation Insertion and casting alone would go to the root operation Immobilization in the Placement section of PCS.

Let’s take a look at the table for Reposition (Reduction) for the Humerus bone of the upper extremity

0 Medical and Surgical
P Upper Bones
S Reposition Moving to its normal location or other suitable locational or a portion of a body part

Body Part
Approach Device Qualifier
C Humeral Head, Right
D Humeral Head, Left
F Humeral Shaft, Right
G Humeral Shaft, Left
H Radius Right
J Radius Left
K Ulna Right
L Ulna Left
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
4 Internal Fixation Device
5 External Fixation Device
6 Internal Fixation Device, Intramedullary
B External Fixation Device, Monoplanar
C External Fixation Device, Ring
D External Fixation Device, Hybrid
Z No Device
Z No Qualifier

The table above is not the complete table as it is quite large due to the fact that it is for all upper body bones; however, for the sake of this article let’s look at the device options for the bones of the arm.  We have basically two options - internal fixation and external fixation when Reduction of a fracture has been done.  Most coders know that internal fixation means rods, plates, or screws are inserted but we also have an option for an intramedullary device. An intramedullary device is a nail or rod which is placed in the marrow canal of long bones.  These rods or nails share the load of the body allowing the fracture to heal and the patient to put weight on the extremity sooner. 

The external device options in the PCS table are Monoplanar, Ring, or Hybrid.  A monoplanar device is a device attached to one side of the extremity, a ring is a device that goes around the fracture site, and a hybrid device is one that has a combination of monoplanar and ring.  It can also be a combination between pins and wires. Rings can be half rings depending on the location of fracture and allowing the body to bend in a certain area. The device chosen for fixation is not only dependent on the type and location of fracture but a patient’s comorbid conditions. 

The table for Insertion has the same options as the table for Reposition.  The definition for Insertion is putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not take the place of a body part.

I mentioned earlier, comorbid conditions may play a role in the decision of what type of fixation the surgeon may use and I want to go into a bit more detail regarding that comment. Conditions with the potential for compromising healing such as rheumatoid disease, peripheral vascular disease, diabetes mellitus may drive the decision to use external fixation. Also, in the setting of osteomyelitis not placing an implant into the infected area is a better decision. 

External fixation is also less disruptive to soft tissues, osseous blood supply and the periosteum in general. Another benefit to an external fixator device is that it can be adjusted postoperatively.

Lastly, keep in mind when coding fracture treatment, if multiple fractures are treated the primary procedure would be the one most related to the principal diagnosis.


Understanding Burn Treatment Procedures

Submitted by Peggy Hapner, RHIA, CCS, CASCC

Burn treatment procedures can vary depending upon the degree of the burn, the size and depth of the burn and the location. Outpatient treatment of burns can range from dressings to surgical debridement. In this article we are going to discuss the different types of burn treatment.

In the CPT coding manual local treatment of burns have a range of codes that can be assigned based on the documentation submitted by the physician. CPT codes 16000-16036 are assigned when the treatment is for the burn surface only. Code 16000 is assigned when the burn is classified as a first degree burn and the treatment is initial and local (meaning burn cream and dressed). Codes 16020-16030 describes dressing and/or debridement of partial-thickness burns performed initially or subsequently. In codes 16020-16030 the percent of body surface must be documented by the physician in order to capture the correct code. In the CPT coding manual the Professional Edition the Lund-Browder Diagram and Classification Method Table for Burn Estimations is used to determine the extent, depth and percentage of burns in different ages of patient’s. You can also access this chart on the internet.

CPT codes 16035-16036 describes escharotomy initial and each additional incision. When a burn begins to heal there are times when the skin will begin to pull. This pulling causes severe pain for the patient and the physician will incise into the burn to alleviate the pulling while the burn heals.

When the burn is deeper than local treatment can repair the physician may need to perform debridement. There are several types of debridement that may be used. Let’s discuss each of the types of debridement and where you might find them in the CPT code book.

Surgical Debridement – when the burn is deeper and requires a surgical debridement of subcutaneous tissue, muscle/fascia or bone using scalpels, forceps, scissors or other instruments assign codes 11042-11047 depending upon the depth of the debridement. The physician will remove any dead tissue or slough and irrigate the wound to remove any particles in the wound bed. Dressings are placed to protect the wound. Surgical debridement may need to be performed multiple times to promote wound healing. Most typically in the outpatient setting the subcutaneous depth is the deepest you will see. These codes are assigned based on the square centimeters of the wound – which needs to be documented by the physician.

Mechanical Debridement – is assigned to codes 97597-97598 which describes Active Wound Care Management – Selective Debridement. In this procedure the physician uses high pressure water jet with or without suction, scissors, scalpel or forceps to remove fibrin, devitalized epidermis or dermis, debris, exudate and/or biofilm from the burn wound. Whirlpool bath is included in these codes.

Chemical Debridement – Non-Selective Debridement entails the use of wet-to-moist dressings, enzymatic, abrasion and larval therapy to aid in the healing of the burn wound. The code for non-selective debridement is 97602 and is assigned per session.

With burn treatment the patient is followed very closely to watch for signs of infections or other complications that may hinder the healing process. Return treatment visits are not uncommon for burn therapy in the outpatient setting. When in doubt of the type of treatment provided to the patient query the physician to clarify any confusion in the documentation.e



E/M ProFee

Critical Care Codes

Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA, Lead Pro-Fee Auditor

What IS Critical Care?

Services reported with CPT codes 99291 and 99292 are used when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

ICU-comicCritical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. 

As a coder one cannot assume that because the patient is in considerable organ system distress that this qualifies for critical care. Providing medical care to a critically ill patient should not be automatically deemed to be a critical care service for the sole reason that the patient is critically ill or injured. The provider needs to document the time and patient management spent in critical care treatment.

Critical care services must be medically necessary and reasonable.

Here are some examples of patients whose medical condition may not warrant critical care services:

  1. Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long-term management of the ventilator dependence.
  2. Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long-term management of the dialysis dependence (refer to Chapter 8, §160.4). When a separately identifiable condition (e.g., management of seizures or pericardial tamponade related to renal failure) is being managed, it may be billed as critical care if critical care requirements are met. Modifier –25 should be appended to the critical care code when applicable in this situation.

Here are some examples of patients whose medical condition may warrant critical care services:

  1. An 81-year old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.
  2. A 67-year old female patient is 3 days status post mitral valve repair. She develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support.

Examples of patients who may not satisfy Medicare medical necessity criteria, or do not meet critical care criteria or who do not have a critical care illness or injury and therefore not eligible for critical care payment:

  1. Patients admitted to a critical care unit because no other hospital beds were available;
  2. Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose); and
  3. Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.

Providing medical care to a critically ill patient should not be automatically deemed to be a critical care

Physician Time

Critical care is a time-based service and for each date and encounter entry, the physician’s progress note(s) need to document the total time that critical care service were provided.

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.

Counting of Units of Critical Care Services

The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291on the same date of service.

The following services when performed on the day a physician bills for critical care are included in the critical care service and should not be reported separately:

  • The interpretation of cardiac output measurements (CPT 93561, 93562);
  • Chest x-rays, professional component (CPT 71010, 71015, 71020);
  • Blood draw for specimen (CPT 36415);
  • Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090);
  • Gastric intubation (CPT 43752, 91105);
  • Pulse oximetry (CPT 94760, 94761, 94762);
  • Temporary transcutaneous pacing (CPT 92953);
  • Ventilator management (CPT 94002 – 94004, 94660, 94662); and
  • Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600).

No other procedure codes are bundled into the critical care services. Therefore, other medically necessary procedure codes may be billed separately.

Teaching Physician Criteria

In order for the teaching physician to bill for critical care services the teaching physician must meet the requirements for critical care described in the preceding sections. For CPT codes determined on the basis of time, such as critical care, the teaching physician must be present for the entire period of time for which the claim is submitted. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. (See IOM, Pub 100-04, Chapter12, § 100.1.4)


Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time.


A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician medical record documentation must provide substantive information including:

  1. the time the teaching physician spent providing critical care, 
  2. that the patient was critically ill during the time the teaching physician saw the patient,
  3. what made the patient critically ill, and
  4. the nature of the treatment and management provided by the teaching physician.

The medical review criteria are the same for the teaching physician as for all physicians. (See the Medicare Claims Processing, Pub. 100-04, Chapter 12, §100.1.1 for teaching physician documentation guidance.)

Unacceptable Example of Documentation:
“I came and saw (the patient) and agree with (the resident)”.

Acceptable Example of Documentation:
"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

Again, the time spent by the resident, without the presence of the teaching physician, cannot be billed by the teaching physician as critical care, or, any other time-based service.

CMS Transmittal 2997
CPT 2019 Professional Book


Anatomy Feature

Anatomy of Coding Open Gustilo Fractures

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

In ICD-10-CM open fractures of the forearm (S52.-), femur (S72.-), lower leg and ankle (S82.-) are based on Gustilo classification types and are denoted in the seventh character extension. This way of classifying open fractures is the most commonly used system. Open fractures are organized by energy of the fracture, amount of soft tissue damage, and degree of contamination. This information is necessary for proper treatment protocols and communication between providers. Because open fractures carry a higher risk of infection, wound complications, and possible nonunion this is also denoted in the 7th character within ICD-10. This is illustrated below.

A Type I open fracture has a wound less than 1 cm with minimal soft tissue injury, the wound bed is clean and the fracture is usually a simple transverse, short oblique fracture, with minimal comminution. A Type II open fracture has a wound that is greater than 1 cm with moderate soft tissue injury and a fracture is usually a simple transverse, short oblique fracture, with minimal comminution. In ICD-10-CM the seventh character for type I and type II are grouped together according to the table below:

7th Character Description


Initial encounter for open fracture type I or II (NOS)


Subsequent encounter for open fracture type I or II with routine healing


Subsequent encounter for open fracture type I or II with delayed healing


Subsequent encounter for open fracture type I or II with nonunion


Subsequent encounter for open fracture type I or II with malunion

Notice that the complications of delayed healing, nonunion and malunion are also identified as we now know open fractures carry a higher risk of these occurring.

Type III open fractures are the most difficult to classify and treat due to the various injury patterns of soft tissue loss and bone fragments resulting from high velocity impact or severe crushing injuries. These fractures have extensive soft tissue damage, foreign body contamination, bone exposure, and severe vascular injury.

Type III open fractures are further divided by severity and categorized with A, B, or C subtypes. I could go into all the gory details of each designation but in the end, it doesn’t really matter for coding purposes as all type III open fractures are all grouped together. See table below.

7th Character Description


Initial encounter for open fracture type IIIA, IIIB, IIIC


Subsequent encounter for open fracture type IIIA, IIIB, IIIC with routine healing


Subsequent encounter for open fracture type IIIA, IIIB, IIIC with delayed healing


Subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion


Subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion

An initial encounter for a type III open fracture will most likely have consults and/or operative notes from orthopedics, vascular, neurology, and plastics to assess and repair the severe damage caused by this type of injury.

ER-Record-350X350-BCDI Corner

Documentation Nuggets in ER Record

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

As a coder or CDI specialist we are one of the privileged few who get to pour over every nook and cranny of a patient’s medical record. All the while, piecing everything together to construct a story with data from admission to discharge. This article is going to address analysis of the very first pieces of documentation on admission – The Emergency Room Record. Our mission is to determine the condition that is chiefly responsible for admission to the hospital and to determine what other conditions may be present and need treatment. We scour for conditions that are being clinically evaluated, therapeutically treated, or require close nursing monitoring as these conditions could impact the LOS, ROM, SOI, and/or provide a CC/MCC impacting the final DRG assignment.

The ER physician’s notes should explain the patient’s chief complaint and physical assessment. This will provide clarity for conditions present on admission and support the medical necessity for the admission. The ER physician should provide a working diagnosis as part of the final assessment. Be sure to review orders for tests and the diagnostic work up plan as these may provide additional details needed for coding. Keep in mind that the condition “chiefly” responsible for admission may be a developing one and/or ruled out later in the patient’s stay.

Documentation from the ER physician, physician assistants, or nurse practitioner can be used for code assignment; HOWEVER, the attending physician gets the final word. This is important to remember because if documentation is unclear or conflicting between these providers the attending will need to be queried.

The ER nursing assessment can be a gold mine of information and should reinforce the physician’s documentation. The gold nuggets of information lie with identifying medications the patient is currently taking at home or meds given in the ER as these may offer clues to secondary diagnoses. Nursing documentation may have procedure details, a thorough history including allergies and previous surgeries which are all important as these may impact the care the patient recieves. They could also provide additional clinical details to form a query to the provider if necessary. Also of importance are any documented changes in the patient’s status. All changes should be communicated to the physician and could hold clues to a more specific diagnosis. In one source, it was noted that nursing curriculum includes many hours devoted to proper documentation and charting guidelines, while medical school curriculum devotes less than two hours. Whether this is still true or not is unclear; however, this stresses the fact that reviewing nursing documentation shouldn’t be dismissed.

Lastly, reviewing EMS run sheets if available is helpful as well. It is here that information regarding loss of consciousness and Glasgow coma scale may be noted. Procedures performed in the field such as intubation, urinary catheter placement, and IV medications is documented. Additional details regarding the patient’s home situation may also prove to be useful information.

In conclusion keep in mind the 7 criteria for high quality documentation: Legible, reliable, precise, complete, consistent, clear, and timely, and if any of these is in question a query may be warranted.



Pharmacology Spotlight


Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Furosemide, generic for Lasix® is a loop diuretic and is given to reduce excess fluid in the body. Conditions such as congestive heart failure, cirrhosis of the liver, and kidney disease can cause excess fluid also known as edema. When a patient presents to the ER in acute decompensated congestive heart failure (ADHF) IV diuretics (Lasix) is typically started to rapidly decrease fluid overload. This rapid decrease of excess water in the body leads to large amounts of sodium lost through urination. Careful monitoring of potassium and magnesium levels is typically done to decrease risks of arrhythmias associated with the loss of electrolytes.

As mentioned above loop diuretics (Lasix) works by making the kidneys process more fluid by interfering with the transport of salt and water across certain cells in the kidney known as loop of Henle. Each kidney contains thousands of these loops. The end result is less fluid in the bloodstream allowing room for any excess build up in lungs to be released. This reduces shortness of breath and edema caused by the acute decompensated CHF.

Lasix tablets are supplied in 20, 40, or 80 mg tablets. When doses exceed 80 mg per day for a prolonged period careful monitoring through lab tests is advisable. Geriatric patients are particularly vulnerable to adverse reactions so they are typically started on a low dose and are monitored closely..

Assign ICD-10-C

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