Question

QUESTION 14

1. CASE STUDY 71: The ER provider adequately documents the skin repair for coding. Of the following information, which would be helpful for the provider to include in the documentation to help us completely code all charges for this case?

   	A.	Documentation of the patient's length-of-stay.
   	B.	Whether tetanus booster (vaccine) was administered.
   	C.	Number of nurses required for procedural assistance.
   	D.	A copy of the anesthesia services report. CHAPTER 9 Emergency Department 79 Case 71: Leg Laceration LOCATION: Emergency Department L'ATIENT: DcDe Clites PHYSICIAN: Paul Sutton, M.D. CHIEF COMPLAINT: Right leg laceration HISTORY OF PRESENT ILLNESS: A 59-year-old female presents with the chief complaint of a right leg laceration. The patient was at work today when a locker fell on top of her and she sustained blunt trauma to the right shin area. She cannot remember her last tetanus shot. OBJECTIVE: She has a 4.0-cm flap laceration over the lateral aspect of the right mid shin. The full extent of this wound is seen. It is through the dermis into the subcutaneous fat but no underlying muscle involvement. ASSESSMENT: Right leg laceration. PLAN: This is cleansed with normal saline. One Percent lidocaine with bicarb was used for loca! anesthesia. This was irrignted with saline and sulured first with 4-0 Vicryl a total of 1 suture in the dermis and then 5-0 Ethilon a total of about 10 mattress sutures in the skin. Suture removal in 10 days and a wound care sheet was given.

Answer 1

Among the following information option "D" , is useful to code completely and get all the charges.

Rationale : The procedure involved which can be reimbursed is Anaesthesia.For this procedure to be billed there must be a clear documentation of all the times of the procedure.That is from the time the procedure has started including the preoperative preparation and ends with the physician returning from the operation.According to this time units the total bill will be claimed or charged.

Where as length of the stay will always affects hospitals.The more length of stay will make hospitals to pay more in the allotted DRG codes.So this does not help for billing.Vaccines administered for an injury will any way reimbursed but this will not help to get full pay.Also the information regarding nurses assistance also will not work as it does not notify the time spent or the seriousness.Only Anaesthesia records can calculate the CPT codes and modifiers to get effectively reimbursed.