CEDC flashcards

33 cards. Read the term and the definition here. The deck at the top of this page is optional.

Facility vs professional component

Facility component covers hospital resources and overhead billed by the hospital; professional component covers physician work billed by the physician. Each is coded and paid separately in the ED.

Place of service 23

POS 23 designates the emergency department of a hospital. Hospital-based ED physicians report professional E/M codes 99281–99285 with POS 23.

EMTALA screening requirement

EMTALA requires hospitals to provide an appropriate medical screening examination to anyone presenting to the ED, regardless of insurance or ability to pay.

Observation service codes

Observation is a facility-level service reported with G0378 (hourly) and G0379 (direct admission). It is distinct from ED E/M levels and physician professional coding.

Facility point system

Many hospitals assign points for history, exam, and interventions to determine the facility ED E/M level, rather than using CPT MDM or time rules.

Teaching physician rule

For professional ED coding, the teaching physician must document their own participation and medical decision making; a resident's note alone cannot support the professional service.

ED E/M selection basis

ED E/M codes 99281–99285 are selected by medical decision making (problems, data, risk), not by time spent with the patient.

MDM three elements

Medical decision making comprises number and complexity of problems, amount and complexity of data reviewed, and risk of complications, morbidity, or mortality.

Two-of-three MDM rule

The E/M level is supported when two of the three MDM elements meet or exceed that level; the highest two elements determine the code.

Critical care time threshold

99291 covers the first 30–74 minutes of critical care; 99292 is added for each additional 30 minutes. Time excludes separately billable procedures.

Modifier 25 with procedures

Modifier 25 reports a significant, separately identifiable E/M service on the same day as a procedure when the E/M work is above the procedure's usual work.

No new/established for ED

ED E/M codes 99281–99285 do not distinguish new versus established patients; that distinction applies to office and outpatient codes only.

Wound repair complexity groups

Repair codes are grouped as simple (12001–12021), intermediate (12031–12057), and complex (13100–13160), selected by depth and work required.

Length-based repair coding

Repair code selection depends on total wound length in centimeters within the same complexity group and same anatomic site group.

Multiple wound summation

Wounds in the same complexity group and same site group are summed and reported once at total length; different site groups may be reported separately.

Simple vs intermediate repair

Simple repair is single-layer closure of superficial wounds; intermediate includes layered closure or extensive cleaning of heavily contaminated wounds.

Complex repair criteria

Complex repair requires more than simple or intermediate work, such as layered closure with scar revision, debridement, or retention sutures.

Debridement coding basis

Debridement codes 11042–11047 are selected by surface area in square centimeters and by depth (skin/subcutaneous versus muscle/fascia).

Fracture care global package

Fracture care codes include the initial evaluation, application of the first cast or splint, and normal follow-up care, billed once at the initial visit.

Closed treatment with manipulation

Closed treatment with manipulation (e.g., 25605) requires documented reduction of a displaced fracture without surgical incision.

Open treatment with fixation

Open treatment codes (e.g., 25607–25609) are reported when a fracture is surgically exposed and stabilized with internal fixation hardware.

Splint application coding

A splint applied at the initial visit is included in fracture care; a splint applied without fracture treatment may be reported separately (29105–29131).

Dislocation reduction codes

Dislocation and subluxation codes (e.g., 23650–23675 shoulder, 27250–27256 hip) describe closed or open reduction of the joint.

Endotracheal intubation code

Emergency endotracheal intubation is reported with 31500 and is separately reportable from critical care or ventilation management services.

CPR reporting

CPR (92950) is reported once per cardiac arrest event and is not time-based in the same manner as critical care services.

Chest tube placement

Chest tube placement (32551) and thoracentesis (32400–32405) are physician procedures that include imaging guidance when performed.

Central line coding

Central venous catheter placement (36555–36571) is reported by site and type; a significant E/M may be separately reported with modifier 25.

External cause codes

Injury encounters require an external cause code (V, W, X, Y) describing mechanism; the injury code is sequenced first followed by the external cause.

Signs and symptoms coding

When no definitive diagnosis is established at the encounter, signs and symptoms such as chest pain (R07.9) or fever (R50.9) are coded.

Laterality and encounter type

Injury codes require laterality (right or left) and encounter type (initial, subsequent, or sequela) to be fully specified.

Ruled-out conditions

Conditions that are ruled out during the ED encounter are not coded as confirmed; code the signs, symptoms, or confirmed diagnosis instead.

Modifier 59 distinct service

Modifier 59 indicates a distinct procedural service and may override NCCI bundling edits when procedures are truly separate and documented.

Modifier 57 decision for surgery

Modifier 57 indicates an E/M service that resulted in the decision for major surgery with a global period of 90 days or more.