Previous Bulletin articles have provided Current Procedural Terminology (CPT)* coding guidance for trauma cases, including: “Coding for damage-control surgery”† and “Effectively using E/M codes for trauma care.”‡ This article presents several clinical scenarios involving penetrating trauma and challenges the reader’s coding knowledge for each example provided.
Trauma Scenario 1
Initial work in ED
A 25-year-old male involved in an accident related to a tractor’s power take-off mechanism arrives at the emergency department (ED) in shock with his right leg nearly amputated at the upper thigh level. The emergency medical service providers had applied a tourniquet in the field, reducing the bleeding from the stump of the leg. The surgeon arrives at the ED and performs the primary and secondary Advanced Trauma Life Support® (ATLS®) surveys, an abdominal and retroperitoneal focused assessment with sonography for trauma (FAST) exam, and exams of the patient’s leg. The surgeon orders administration of blood, antibiotics, and fluids based on the examination, vital signs, and available labs. It is determined that the partially severed leg, which was mangled by the tractor, is unsalvageable. The surgeon spent 30 minutes of critical care services in the ED before deciding to go to the operating room (OR). (See Table 1.)
Table 1. Initial work in the ED
| CPT code(s) to report | Descriptor | Global period | Total Relative Value Unit (RVU) |
| 99291-57-25 | Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes | XXX | 6.35 |
| Evaluation and management (E/M): The initial work in the ED included critical care and met the threshold of time to report 99291. In addition to describing the critical care work performed, it is advisable to document the start and stop time in the medical record. It is also advisable to confirm with any other providers (for example, ED physicians, other surgeons) that you were in charge of the critical care and you will be submitting 99291 for critical care management, since only one provider may report critical care services for a given period of time; that is to say that two or more providers cannot report critical care at the same time. Modifier 57, Decision for surgery, is appended. Modifier 25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, is also appended to indicate that this E/M service was separate and distinct from the 0-day global “minor” procedure code 11043, which is reported for wound debridement in the OR. Coding tip: If a surgeon spends less than 30 minutes of critical care services in an ED before deciding to take a patient to the OR for surgery, an initial inpatient visit code (99221–99223) would be reported with modifier 57 appended for Medicare patients. For non-Medicare patients, when allowed, an inpatient consultation code (99251–99255) would be reported with modifier 57 appended. |
Work in the OR
The patient is taken to the OR where the leg is removed and all nonviable and contaminated tissue is debrided. A total of 140 sq cm of skin, muscle, and fascia around the femur is excised and shortened to healthier tissue. The femur is transected cleanly with a saw. Bleeding is controlled with cautery and ligation. After copious irrigation of all wounds, the tourniquet is let down and hemostasis is obtained. A 100 sq cm negative pressure dressing is placed on the amputated leg stump. At the end of the operation, the patient is maintained on a ventilator with ongoing resuscitation and is transferred to the intensive care unit (ICU). (See Table 2.)
Table 2. Work in the OR
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 27592 | Amputation, thigh, through femur, any level; open, circular (guillotine) | 090 | 19.65 |
| 11043-51 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less | 000 | 4.47 |
| +11046 x 6 units | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | ZZZ | 1.62 x 6 units |
| 97606-59 | Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters | XXX | 0.80 |
| Amputation: Code 27592 is reported for the amputation of femur. Even though the wound is not closed, no modifier is required. Debridement: Codes 11043 (first 20 sq cm) and six units of add-on code 11046 (each additional 20 sq cm) are reported for debridement of the leg stump based on depth (fascia) and size (140 sq cm). The open fracture debridement codes (11010–11012) are not appropriate to report because an open fracture includes two pieces of bone that will be repaired and in this scenario there is no fracture, and only one piece of bone. Modifier 51, Multiple procedures, is appended to 11043 if required by the payor. Modifier 51 is never appended to add-on codes (for example, 11046). VAC: Code 97606 is reported for placement of the negative pressure wound therapy dressing and wound VAC, based on the surface area of the wound (80 sq cm). Modifier 59 is appended to indicate it is a service that is distinct from 27592. In addition, documentation should be clear that the wound VAC was medically necessary because the wound was left open. |
Postoperative work in the ICU
Later the same day in ICU, the surgeon examines the patient and orders a blood transfusion, adjusts intravenous (IV) fluids to stabilize electrolytes/coagulopathy, titrates the ventilator settings, and orders pain medication. In addition, the surgeon needs to replace the wound vacuum-assisted closure (VAC) dressing, which has become dislodged. The surgeon spent 50 minutes total in the ICU; 30 minutes of critical care and 20 minutes to replace the wound VAC. (See Table 3.)
Table 3. Postoperative work in the ICU
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 97606-XE | Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters | XXX | 0.80 |
| Wound VAC: Report code 97606 for replacing the negative pressure wound therapy dressing later in the day in the ICU and append modifier XE, Separate encounter, to distinguish this service from the work performed earlier in the day in the OR. If the wound VAC were replaced on a subsequent date, then modifier 58 (staged procedure) would be appended to 97606. No additional E/M code would be reported for postoperative work. Critical care codes 99291 and 99292 are reported for total time on a given date and not for each patient encounter. The 30 minutes of critical care before surgery plus the 30 minutes postoperative on the same date equal 60 total minutes and are reported with one unit of 99291 for the day. |
Trauma Scenario 2
Initial work in the ED
A 17-year-old male, involved in an early morning bar fight, sustained a single stab wound to the left chest in the mid-axillary line, just below the level of the nipple. He arrives at the hospital awake and alert. The surgeon performs the ATLS primary and secondary surveys and notes that the patient’s airway is patent, but he has decreased breath sounds at the left base. A chest X ray shows left-sided hemopneumothorax, and the surgeon places a chest tube. At this point, the patient complains of a new subscapular pain. Because intra-abdominal injuries are suspected, the patient is taken to the OR. The surgeon spends 40 minutes in the ED, including 20 minutes inserting a chest tube before deciding to go to the OR. (See Table 4.)
Table 4. Initial work in the ED
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 99221-99223-57-25 or 99231-99233-57-25 or 99251-99255-57-25 | Initial hospital care or Subsequent hospital care or Inpatient consultation | XXX | varies |
| 32551-59 | Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) | 000 | 4.54 |
| E/M: Although the patient has a high probability of imminent or life-threatening deterioration, code 99291 for critical care may not be reported because the surgeon’s total time in the ED minus time to insert the chest tube was less than 30 minutes (40 minutes minus 20 minutes). Instead, an initial hospital care code (99221–99223) for Medicare patients or inpatient consultation code (99251–99255) for non-Medicare patients (when allowed) is reported—if all three required key components are met. If all three key components are not met, then a subsequent hospital care code (99231–99233) is reported. No matter which E/M code is reported, modifier 57 is appended. In addition, modifier 25, Significant and separately identifiable E/M service, would also be appended because code 32551 has a 0-day global period. Modifier 25 indicates that the E/M service on the same date was not directly related to the “minor” 0-day global procedure. Chest tube: Code 32551 is reported for placement of the chest tube. When multiple procedures are reported, it is important to check Medicare’s National Correct Coding Initiative (NCCI) edits for code pairs that may be bundled and require a modifier to bypass the payment edit. Modifier 59 is appended to indicate that the chest tube placement is a separate and distinct service from the thoracoscopy procedure that is performed later in the OR on the same date. Because modifier 59 is appended, you do not also append modifier 51 to 32551. |
Work in the OR
The patient is taken to the OR for a laparoscopic exploration. A defect in the diaphragm is identified and blood clots are noted on the anterior surface of the stomach and the left lateral segment of the liver. The operation is converted to an open laparotomy. Upon open exploration, there are three lacerations on the surface of the liver that require suture closure. There is also a 2 cm perforation of the anterior surface of the stomach that is closed primarily in two layers. To assess the extent of intra-thoracic injuries more closely, a thoracoscopy is performed with negative findings for blood or other injury. The diaphragmatic laceration is closed via the abdominal exposure and the abdomen is closed in standard fashion. The patient is transferred to the ICU. (See Table 5.)
Table 5. Work in the OR
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 47350 | Management of liver hemorrhage; simple suture of liver wound or injury | 090 | 39.64 |
| 43840-51 | Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury | 090 | 39.37 |
| 39501-51 | Repair, laceration of diaphragm, any approach | 090 | 24.56 |
| 32601-51 | Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsy | 000 | 8.92 |
| Procedures: Code 47350 (liver repair) would be reported first since it has the highest total work RVU, followed by codes 43840 (stomach repair), 39501 (diaphragm repair), and 32601 (thoracoscopy), respectively. If required by the payor, modifier 51 should be appended to 43840, 39501, and 32601. |
Postoperative work in the ICU
Later the same day, the surgeon spends an additional 40 minutes with the patient and on reviewing progress notes and interval labs, checking the wounds, adjusting pain medication orders, and documenting the visit. (See Table 6.)
Table 6. Postoperative work in the ICU
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| No E/M code would be reported because the postoperative work to evaluate the patient at the patient’s bedside and in the ICU unit does not meet the requirement for reporting a separately identifiable E/M service. It is important to note that an E/M code (99291 or 99231–99233) is not billable for postoperative care related to the surgery. For example, managing an infection at the incision site or managing a bleeder left during surgery at bedside are related to the surgery and not billed as an E/M or critical care. On the other hand, volume issues, septic shock, acute respiratory distress syndrome (ARDS), managing other injuries that were not surgically treated and any clinical issues resulting from the injury—not the surgery—are separately reported with an E/M code and modifier 24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period, appended. There should be a diagnosis for separately identified problem(s) and the critical care time or level of E/M should be only that associated with the unrelated problem. |
Trauma Scenario 3
Initial work in the ED
A 24-year-old male arrives in the ED with a three-inch gash and stab wound to his left flank in the area of his spleen. The surgeon arrives in the ED and performs the ATLS primary and secondary surveys and an abdominal and retroperitoneal Focused Assessment With Sonography for Trauma (FAST) exam. His blood pressure is 90/50 and although he is transiently responsive to blood transfusions, blood continues to drain out of the stab wound. The surgeon feels that emergent exploration is indicated. The surgeon spends 20 minutes in the ED before making the decision to go to the OR. (See Table 7.)
Table 7. Initial work in the ED
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 99221-99223-57-25 or 99231-99233-57-25 or 99251-99255-57-25 Initial hospital care | Initial hospital care or Subsequent hospital care or Inpatient consultation | XXX | varies |
| E/M: Similar to Scenario 2, code 99291 for critical care may not be reported because the surgeon’s total time in the ED was less than 30 minutes. Instead, an initial hospital care code (99221–99223) for Medicare patients or inpatient consultation code (99251–99255) for non-Medicare patients (when allowed) is reported—if all three required key components are met. If all three key components are not met, then a subsequent hospital care code (99231–99233) is reported. No matter which E/M code is reported, modifier 57 is appended. In addition, modifier 25 would also be appended because code 20102 has a 10-day global period. Modifier 25 indicates that the E/M service on the same date was not directly related to the “minor” 10-day global procedure. |
Work in the OR
The patient is taken to the OR, where a midline laparotomy is performed. No significant intra-abdominal injuries are found other than a hematoma of the left flank and body wall. His left colon is partially mobilized and the hematoma is explored and no organ injury is found. The laparotomy wound is closed in routine fashion. Attention is turned once again to the stab wound which is expanded, probed, and debrided. Several bleeding vessels are sutured and cauterized followed by closure of the wound after hemostasis is obtained. The patient is transferred to the ICU. (See Table 8.)
Table 8. Work in the OR
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| 49000 | Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) | 090 | 22.27 |
| 20102-59 | Exploration of penetrating wound (separate procedure); abdomen/flank/back | 010 | 7.38 |
| Abdominal exploration: An exploratory laparotomy and retroperitoneal exploration may both be performed through a midline incision. Code 49010, Exploration, retroperitoneal area with or without biopsy(s) (separate procedure), would only apply (instead of code 49000) if the major procedural initial intent was to explore the retroperitoneum. In this patient’s case, however, the retroperitoneal exploration was minimal and performed after no intraabdominal blood or injuries were found. Therefore, it is appropriate to report 49000. Wound exploration: Code 20102 is reported for exploring the penetrating stab wound to the left flank. Modifier 59 should be appended to 20102 to indicate work at a site that is distinct from the exploratory laparotomy. |
Postoperative work in the ICU
The surgeon spends an additional 20 minutes with the patient and in the ICU later in the day reviewing progress notes and interval labs, checking the patient’s wounds, adjusting pain medication orders, and documenting the visit. (See Table 9.)
Table 9. Postoperative work in the ICU
| CPT code(s) to report | Descriptor | Global period | Total RVU |
| No E/M code would be reported because the postoperative work to evaluate the patient at the patient’s bedside and in the ICU unit does not meet the requirement for reporting a separately identifiable E/M service. |
Learn more
Learn more about trauma and general surgery coding at an American College of Surgeons General Surgery Coding Workshop. By attending a coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation.
The ACS will offer the following workshops in 2018:
- Chicago, IL, April 12–13
- New York, NY, May 17–19§
- Nashville, TN, August 9–10
- Chicago, IL, November 1–3§
At the May and November workshops, a third day is added that is devoted to trauma and critical care coding. More information about the 2018 ACS coding workshops is on 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.
†Barney L, Jackson J, Mabry CD, Savarise M, Senkowski C. Coding for damage-control surgery. Bull Am Coll Surg. 2013;98(8):57-61. Available at: bulletin.facs.org/2013/08/coding-for-damage-control-surgery/. Accessed January 30, 2018.
‡Jackson J, Mabry CD, Savarise M, Senkowski C. Effectively using E/M codes for trauma care. Bull Am Coll Surg. 2013;98(6):56-65. Available at: bulletin.facs.org/2013/06/em-codes-for-trauma-care/. Accessed January 30, 2018.
§These workshops offer a third day with a focus on trauma and critical care coding.
