Trauma and Critical Care Coding

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Learning Objectives

As a result of this course, participants will be able to:

• Describe the surgical global package and what is separately reported for trauma and critical care services
• Distinguish documentation for co-surgeon versus and assistant surgeon services for multiple trauma cases
• Correctly apply surgical and E/M modifiers for trauma and critical care
• Recognize correct trauma diagnosis coding
• Correctly code a variety of trauma procedures and services, including imaging, thoracotomy, damage control surgery, liver, colon and other injuries, vessel repair and sacrifice and new vessel exploration codes
• Differentiate between critical care and non-critical care E/M services
• Demonstrate how to report and document critical care time
• Recognize correct reporting of critical care services within a surgical global period
• Recognize how to report critical care as a teaching physician  

What's On the Agenda

The Global Surgical Package

• Deconstructing your payment: How do payors value physician services?
• Understanding relative value units, surgical, splits and time-based valuation
• What's included in a 90-day global package and what's separately reported?

Documenting and Reporting Co-Surgeon and Assistant Surgeon

• Co-surgeon vs. Assistant: Are you reporting these correctly?
• Multiple trauma surgery with my partner, are we co-surgeons or assistant surgeons?
• What about if we repair different organs?
• What if one leaves before the case is over?
• Multiple trauma with a different specialist: Are we co-surgeons or assistant surgeons? Or do we all bill our own work?
• Payor expectations for co-surgeon and assistant surgeon documentation
• Reimbursement: Difference between co-surgeon or assistant surgeon

Modifiers in Trauma Surgery

• Is there a modifier that reflects the time and effort to do a complete trauma laparotomy? What can I bill for removing a bell full of blood to discover what exactly is injured?
• Will modifier 22 work on the majority of my surgeries because all take extra time and intensity? How often can I append this in trauma? Will it get paid?
• Modifier use in damage control surgery. What is used on the first surgery? What about on the second or third? Will all be paid?
• Repairing several organs, liver, diaphragm, large and small bowel, or more. Will all get paid and which modifiers are needed? What is unbundling okay?

Highlights of Trauma Diagnosis Coding

• Co-morbidities and other injuries: To code or not to code
• Diagnosis codes that support critical care
• Solving the mystery of choosing the seventh character: When is a subsequent encounter not a subsequent encounter?

Trauma Procedure Coding

• Central venous catheter coding
• Emergent procedures: Chest tube, intubation, tracheostomy, pericardial window, TPA in chest tubes, wound exploration, thoracotomy, resuscitation, hemorrhage management
• Imaging and the trauma surgeon: FAST exams, other imaging
• Trauma surgery coding: Liver, spleen, intestine resection/repair, trauma Whipple, fasciotomies, damage control surgery, wound vac coding, pre-peritoneal packing, reporting multiple trauma
• Vessel repair and vessel ligation: Is it separately reported?
• Case scenarios

Wound Repair Coding: Dos and Don'ts

• Simple, intermediate, complex repairs: When are they reported with trauma care?
• New definitions for extensive undermining
• Debridement/wound care therapy: Wound vac use and reimbursement

E/M and Critical Care Coding: Introduction

• Critical care is an audit target! Minimizing your risk by accurate documentation
• Critical care coding and the trauma surgeon

Defining Critical Care

• Medicare vs CPT
• Defining organ system failure: Dissecting critical care criteria

Calculating Time in Critical Care

• Services that can be included in the calculation of critical care time
• Services that may not be included in critical care time
• Applying the primary and add-on critical care codes with different providers
• Documenting time

Concurrent Critical Care Coding

• Partners of the same specialty
• Physicians of different specialties
• Trauma surgeon and intensivists: Who bills?
• The trauma surgeon as an Intensivist. How does billing change?

Critical Care and Place of Service: Where Can Critical Care Be Reported

• ED, inpatient, ICU. Is there a difference?

Critical Care Services and Other E/M Services Provided on Same Day

• Can both be billed? Does sequence matter?
• Medicare
• CPT

Coding Critical Care Services During Preoperative and Postoperative Portion of Global Period of Procedure with 90-Day Global Period

• In trauma cases
• In other scenarios
• Applying E/M modifiers

Documenting Critical Care

• Supporting documentation: What justifies medical necessity and what does not
• Examples of acceptable and unacceptable critical care documentation
• Critical care scenarios

Teaching Physicians and Critical Care: Billing Imperatives

Billing Critical Care for Nurse Practitioners and Physician Assistants