2018 Guideline Updates for Emergency Department Coding and Documentation

January 2018 ~

As of January 1^st, several CPT^® code updates for emergency medicine took effect, including changes to chest x-ray and abdominal x-rays codes, lab test and needle introduction codes, observation codes, and an updated ultrasound of extremities descriptor.

According to the American College of Emergency Physicians (ACEP), much of the evaluation and investigation previously completed during an inpatient visit is now routinely performed in emergency departments. This increase in the intensity services, says the ACEP, has amplified the complexity of coding for the various types of emergency department visits.

Emergency department physicians and coders should take note of the following code changes for 2018:

Chest X-Rays

The existing codes for chest x-rays, 71010-71035, will be deleted (effective January 1^st) and replaced by the following:

• 71045 (Radiologic examination, chest; single view)
• 71046 (Radiologic examination, chest; 2 views)
• 71047 (Radiologic examination, chest; 3 views)
• 71048 (Radiologic examination, chest; 4 or more views)

Abdominal X-Rays

The existing codes for abdominal x-rays, 74000-74022, will be deleted (effective January 1^st) and replaced by the following:

• 74018 (Radiologic examination, abdomen; 1 view)
• 74019 (Radiologic examination, abdomen; 2 views)
• 74021 (Radiologic examination, abdomen; 3 or more views)

Ultrasound of Extremities Descriptors

The introduction to the extremities codes in the ultrasound section has been expanded significantly. The preamble now indicates that CPT^® code 76881 (Ultrasound, complete joint [i.e., joint space and peri-articular soft-tissue structures], real-time with image documentation) “requires ultrasound examination of all of the following joint elements: Joint space (e.g., effusion), peri-articular soft tissue structures that surround the joint (i.e., muscles, tendons, other soft-tissue structures), and any identifiable abnormality.”

To report this code, according to the CPT^®, physicians must also permanently record the images and maintain a written report with a description of each element visualized “or reason that an element(s) could not be visualized (e.g., absent secondary to surgery or trauma).”

When the elements required by CPT^® are not performed, the “limited” code should instead be reported: 76882 (Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g., joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation).

The manual now states that when submitting CPT^® code 76882, a limited evaluation is required which includes “assessment of a specific anatomic structure(s) (e.g., joint space only [effusion] or tendon, muscle, and/or other soft-tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881.”

Laboratory Tests

There are two new laboratory codes for 2018:

• 87634 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique)
• 87662 (Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique)

Needle Introduction

The descriptor for CPT^® code 36140 (Introduction of needle or intracatheter, upper or lower extremity artery) has been updated to with new verbiage to specify that the code refers to either the upper or lower extremity artery.

Observation Care

The preamble to the “Initial Observation Care, New and Established Patient” section and the full code descriptors for 99217-99220 have been updated as follows: “The following codes are used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as outpatient hospital ‘observation status.’”

• 99217 – Observation care discharge day management “includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records.”
• 99218 – Initial observation care, per day, for problems of low severity.
• 99219 Initial observation care, per day, for problems of moderate severity.
• 99220 – Initial observation care, per day, for problems of high severity.
• 99224-99226 – A subsequent observation, for patients held in observation status for more than two calendar dates.
• 99234-99236 – Observation or Inpatient Care Service (including admission and discharge services), for patients admitted to observation care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date.

Critical Care

The following critical care codes are to be reported when services are provided to critically ill patients in the emergency department:

• 99291 – Critical Care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
• 99292 – Critical Care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes.

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Source(s): SuperCoder; ACEPNow;