Coding John Doe
It was a dark and stormy night. The alcohol and cocaine didn’t help either. John Doe was found in an urban-slum alleyway behind a dumpster and surrounded by broken glass. A witness states that the patient was assaulted with a glass bottle, lost consciousness for a few minutes and then began to respond. Brought in by EMS and hemodynamically stable, he opens his eyes and withdraws all extremities to noxious stimulus; and his speech is incomprehensible. He is without focal deficits, but with signs of head trauma and obvious intoxication. The trauma team performs their survey. It is clear that this is isolated head trauma, so they sign off. A computed tomography (CT) scan of the head shows a modest right frontal contusion without edema. You admit the patient to the neurosurgical intensive care unit (NICU) and provide the required intensive care.
With this edition of Coding Clarity, we will review the case of John Doe, a patient we have encountered countless times, who serves as the source of myriad 3 a.m. phone calls with residents as well as a continued source of billing and coding frustration. We will follow his odyssey from the Scylla and Charybdis of the alleyway to his Ithaca (the nursing home), reviewing coding tidbits along the way. Let’s start at the beginning:
Initial Encounter and Diagnosis
We first meet John Doe in the trauma bay of an inner city teaching hospital where he is admitted to the NICU after assessment. A comprehensive history and examination is performed to determine that his problem is of a high severity, and then some decisions of high complexity are made (99223). Had the patient been assessed prior to the order to admit, then a high severity emergency department encounter may have been billed (99285). With a Glasgow Coma Scale (GCS) of 8, it is decided that he should be admitted to the NICU and an intracranial pressure (ICP) monitor should be placed (decision to perform surgery modifier -57). His diagnosis is contusion and laceration of the right cerebrum with loss of consciousness of 30 minutes or less, initial encounter (S06.311A). Keep in mind: all subsequent encounters should be coded as S06.311D. John Doe is taken to the operating room (OR) and a right-sided ICP monitor is placed via twist drill. His opening pressure reads 10 mmHg (61107). A Foley catheter is also placed as a distinct procedural service (51702-59).
The Clot Thickens
John Doe returns to the NICU and is stable overnight, with ICP’s in the 6-12 mmHg range. On rounds the next day, he is found unresponsive, with ICP’s slowly climbing to 20 mmHg. It is found that the monitor is working reliably, his head is midline, head of bed is 30 degrees, temperature is 98.6 F and Na 140. He is intubated emergently (31500), a central line is placed (36556) as well as an arterial line (36620).Venipuncture for specimen is performed (36415), a gastric tube is placed (43752), a chest X-ray is taken and interpreted (71010, 71015, 71020), and he is taken for a repeat CT head scan, which shows blossoming of the contusion, with cerebral edema. While it is unlikely that the neurosurgeon on call would be the one performing some of these interventions, for the sake of this exercise, we will assume that he or she is. One hour was utilized to perform critical care (99291). His diagnosis is now contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, subsequent encounter (S06.310D). Traumatic cerebral edema with loss of consciousness of 30 minutes or less, subsequent encounter is then added (S06.1X1D). Upon returning to the OR, the ICP monitor is removed, a right-sided decompressive hemicraniectomy without evacuation of hematoma or lobectomy, which was unplanned, is then performed (61322-78). An external ventricular drain (EVD) was placed on the left side via burr hole (61107-78). Afterward, ICP’s normalized, and the patient had progressive improvement in his neurologic function over a two-week period.
John Doe has made a lot of progress, but it is a struggle to wean him off of his EVD, and it is clear that he has developed post-traumatic hydrocephalus (G91.3) in addition to the cerebral contusion, sequela (S06.311S). At this point, the cerebral edema is completely resolved. He is taken back to the OR, the EVD is removed, and a ventriculoperitoneal shunt is placed, done in conjunction with a general surgeon who performs the abdominal portion (62223-62 -78).
John Doe recovers from the procedure and is transferred to a lower level of care out of the ICU, under a hospitalist service. Two weeks elapse, and the he is making progress with physical therapy. He is still awaiting financial clearance for a skilled nursing facility, complains of positional headaches with bouts of delirium, and his flap is noted to be sunken. He returns to the OR, yet again, for replacement of his bone flap, which was staged and foreseeable (62143-58), with resolution of his headaches. He is discharged to his nursing home, and so concludes our saga.
John Doe has taught all of us, at one point or another, the basics of how to take care of a sick neurosurgical patient. Even beyond that, he continues to teach us in the realm of coding and billing. The themes are identical: ownership of the patient, diligence and attention to detail. These principles hold true on the wards, in the OR and in our electronic medical records (EMRs). As our systems of health care changes and as our delivery of health care and reimbursements are increasingly scrutinized, it becomes more important than ever to pay attention to detail and to appropriately code for every service that is legitimately provided and documented.
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