MES - Midwest Emergency Services, LLC

By: James M. Fox, M.D., M.B.A., F.A.C.E.P. and Sandra A. Steele, C.P.C., C.P.M.A., C.E.D.C.

It is important to complete your procedure note shortly after the procedure so that essential information is documented.  Details of the procedure will help your coder to assign the correct CPT code and receive the maximum, allowable reimbursement for your services.

Document your findings (reason for the procedure), any complications, anesthesia used (if any) as well as the name of the physician performing the procedure.  Also, if applicable, document that the attending ER physician was present during the key portion of any procedure performed by a resident. Many documentation systems offer procedure notes that can be printed on demand or most EHRs will allow you to drop in a template to allow for thorough documentation of procedures.   Specific information that will be helpful includes:

INCISION & DRAINAGE – document the breakup of loculations and/or the placement of packing.  There is a 73% increase in reimbursement between a simple I&D and a complex  I&D.

 NAILS – document if you removed the nail plate, evacuated a subungual hematoma and if the nail bed was repaired.  Repairing a nail bed is worth an additional 147% in reimbursement over a simple repair to a finger or toe.

 LACERATIONS – document the length of the laceration in centimeters.  How the wound was repaired; sutures, staples or tissue adhesives, number of layers repaired as well as any foreign bodies removed.  A 4.5 cm laceration on the chin that requires a layered closure is reimbursed 192% more than the simple (one layer) closure of the same length laceration.

 FRACTURE & DISLOCATION TREATMENT – document whether or not manipulation was performed on a fracture.  For dislocations include the joint, for example IP or MCP, and also if the relocation was successful.  Reimbursement for a MCP relocation is 20% more than an IP – commercial carriers pay approximately $350 - $400 for this procedure.

 NASAL EPISTAXIS – note how the control was achieved; limited cautery, simple gauze packing, extensive cautery or use of a nasal tampon – reimbursement is increased 42% if the control of an anterior nasal hemorrhage is complex. 

 REMOVAL OF FOREIGN BODY FROM THE EYE – note the location of the foreign body, conjunctival; was the foreign body superficial or embedded.  Did a corneal foreign body removal require the use of a slit lamp?  Using a slit lamp increases reimbursement by 37%.

 CPR – The physician may report this code whether actually performing compressions or directing these activities while other staff performs CPR.  Document that CPR was performed and sign the code sheet if available.  CPR can be billed in addition to your visit code.  Commercial reimbursement for CPR is about $250.00.

These specific pieces of information can greatly affect reimbursement for a procedure.  As you can see your additional time documenting a complete procedure note will allow for a significant increase in reimbursement.