The March 2018 Bulletin included an article about Current Procedural Terminology (CPT)* coding guidance for penetrating trauma.† This article presents clinical scenarios involving blunt trauma and challenges the reader’s coding knowledge for each example provided.
Trauma scenario 1
A 27-year-old unrestrained female driver is involved in a motor vehicle collision. Emergency medical service personnel intubate her at the scene. The trauma surgeon meets her upon arrival at the trauma bay and performs the Advanced Trauma Life Support® (ATLS®) primary and secondary surveys. The patient is hypotensive and tachycardic. Radiographic views of her chest reveal multiple bilateral rib fractures and bilateral pulmonary contusions. A pelvic X ray is negative for fractures. A focused assessment with sonography for trauma (FAST) exam of the chest and abdomen is performed with permanent recording. The FAST exam reveals fluid in the right upper quadrant. Crystalloid and colloid resuscitation is initiated, but the patient fails to respond.
The patient is taken to the operating room (OR), where the surgeon performs a laparotomy and immediately identifies a large stellate laceration of the right lobe of the liver. The laceration and the remainder of the abdomen are packed. Resuscitation continues, and the patient becomes stable. Upon further exploration, no other intra-abdominal injuries are identified. The liver packing is removed, the wound edges are debrided, and several bleeding vessels are controlled with clips and cautery. Because of diffuse oozing of blood, the liver is repacked and an 80 sq cm negative pressure dressing is placed on the abdomen for temporary closure.
The patient is transported to the intensive care unit (ICU). The surgeon places a subclavian line for central venous pressure monitoring. The surgeon also places a radial arterial line to monitor mean arterial pressure. Volume resuscitation is managed. Ventilator settings are adjusted. The surgeon spent 35 minutes in the emergency department (ED) and 20 minutes in the ICU, exclusive of time for reportable procedures. For correct reporting of codes for the surgeon’s work on day one, see Table 1.
On day two, the surgeon examines the patient in the ICU and adjusts the ventilator settings to optimize oxygenation. Interval chart notes are reviewed. Because the patient has stabilized, she is returned to the OR for a second look. The surgeon removes the wound vac (vacuum-assisted closure) and liver pack, and hemostasis is established. No new abnormalities are identified. Drains are placed and the patient’s abdomen is definitively closed. The patient is returned to the ICU.
Later the same day, the surgeon confers with ICU clinical staff, reviews interval chart notes, examines the patient, and checks the abdominal wound and drain. The surgeon spends a total of 35 minutes conducting an evaluation and management (E/M) of the patient on day two. For correct reporting of codes for the surgeon’s work on day two, see Table 2.
Trauma Scenario 1
Trauma scenario two
A 45-year-old male is crushed between a forklift and loading dock. He is intubated in the field and is hemodynamically stable but hypoxic upon presentation in the trauma bay. The ventilator is changed to optimize his oxygenation. ATLS primary and secondary surveys are performed. The patient has experienced significant tissue loss in the perineum near the anus and extending to the left gluteal region. A rectal exam reveals disruption of the rectum and gross blood. He has obvious deformities to his left chest wall and pelvis. Chest and pelvis radiographs are taken and reveal multiple left-sided rib fractures, as well as a left pulmonary contusion. A non-displaced left-sided acetabular fracture also is noted.
The patient remains stable and is taken to the OR for an exploratory laparotomy and washout of the perineal injury. The laparotomy reveals anorectal injury. Because of this injury and massive tissue loss in the perineum, the surgeon performs a diverting colostomy. Upon further exploration, the surgeon identifies no other intra-abdominal injuries and closes the laparotomy incision over drains, subsequently performing washout and debridement of all devitalized tissue of the perineum, measuring 10 cm by 15 cm. The debridement is to the level of bone, but bone is not debrided. A 200 sq cm negative pressure dressing is placed on the perineal wound using multiple pieces of dressing to conform to the anatomy and one suction drain. The surgeon admits the patient to the ICU. Later the same day, the surgeon reviews interval chart notes, examines the patient, assesses the ostomy and wounds, and adjusts pain medication. The surgeon spent 40 minutes in the ED and 25 minutes in the ICU, exclusive of time for reportable procedures (for correct reporting of the surgeon’s work, see Table 3).
Trauma Scenario 2
Learn more about trauma and general surgery coding at an American College of Surgeons (ACS) General Surgery Coding Workshop. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation.
The ACS will offer the following workshops for the remainder of 2018:
- Boston, MA, October 21–22 (this workshop is offered during the Clinical Congress 2018)
- Chicago, IL, November 1–3 (this workshop offers a third day with a focus on trauma and critical care coding)
For more information about the 2018 ACS coding workshops, visit the ACS website.
*All specific references to CPT codes and descriptions are © 2017 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
†Lieberman J, Senkowski C, Mabry CD, Nagle J. Test your CPT coding knowledge for penetrating trauma. Bull Am Coll Surg. 2018;103(3):46-50. Available at: bulletin.facs.org/2018/03/test-your-cpt-coding-knowledge-for-penetrating-trauma/#.WvMLIHZG2ig. Accessed June 29, 2018.