Short leg Splint coding guide for ED Facility coders

Emergency Department (ED) coding is limited to only 5 codes, ranging from 99281-99285. But, in ED facility the medical coders have to capture both the surgery procedures and the infusion/injection/hydration codes documented in the medical report. Some of the exam during ED visit include placement of splint like short leg splint, which are necessary to be coded with ED procedure codes. The documentation should complete support for any exam or infusion/injection codes for coding them in the ED medical report.

ED medical reports codes with low risk may not have any documentation of any procedures because of less complexity. For example, if a patient of 30 years gets a sudden abdomen pain and comes to ED visit, but the ED physician finds nothing and documents abdominal pain only in the final impression. So, these reports will fall in 99281 or 99282 ED codes which has no complex disorder or disease.

But, ED visit codes 99283-99285 will have the chance of high risk and high complexity, because the patient may come with a complex problem to the ED physician. For example, the patient get a leg injury and comes to ED physician and the physician documented a fracture in the foot in the final impression. In such scenarios, the patient must have gone through foot x-ray and also any fracture manipulation procedure.

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So, Emergency department coding has two important points to capture.

• Capture all the procedures documented in the Emergency department (ED) visit report.
• Capture all the infusion/injection/hydration services codes

The most common procedures found in the ED visit medical reports are given below:

• Simple Repairs of wound
• Application of short leg splint
• Removal of Foreign Body
• Fracture Manipulation CPT codes

Their are many other procedures as well along with the above ones. It all depend on the patient chief complaint, and the what the procedures has to be performed to resolve the patient problems. Now, today I am only going to share about how a trauma patient is treated with a short leg splint and the supporting documentation for coding this splint.

Below I am sharing a coded ED medical report in which the documentation clearly support for coding short leg splint. This report which help you to code ED report with short leg splint.

Read also: Sample coded ED chart for CPT code 99282

Sample Emergency Department (ED) Coded Report for Splint 

Chief Complaint & History of Present Illness :    
motorcycle accident 

Patient is a 26-year-old male brought in as a limited trauma activation status post motorcycle accident.He was traveling approximately 25 mph, a raccoon ran out in front of him, he slid, laid the bike down, and sustained road rash to His abdomen and left leg.He has pain and swelling in the left ankle.Did not hit his head, did not lose consciousness.No headache, no neck pain, no chest or abdominal pain.No back pain.No other symptoms or complaints. patient is declining pain medication at this time.

Medical Decision Making (MDM) :   patient presents following motorcycle crash, and has road rash, and pain and swelling of the left ankle.X-rays demonstrate an unstable ankle fracture but without dislocation.There is no indication for ED closed reduction or emergent surgery, however, this will require operative repair as an outpatient, according to orthopedic consultant.Splint was placed. Differential diagnosis includes significant intracranial injury, C-spine fracture, focal neurologic deficit, altered mental status,  significant injury to the chest, abdomen, pelvis, I do not believe any above was present.Diagnoses considered not limited to those discussed here.

Plan: Follow up with Orthopedic surgery in the next 3-5 days.Norco, Colace, Zofran p.r.n..May also use over-the-counter ibuprofen.Strict return precautions given and discussed.Wound care as discussed.

ED Diagnosis (Current Problem List) :   
Problem Associated ICD-10-CM Code Status Onset 
Closed fracture of shaft of left fibula Active 2019 
582.432A – DISPLACED OBLIQUE FRACTURE OF SHAFT
OF LEFT FIBULA, INITIAL ENCOUNTER FOR CLOSED 
FRACTURE 
Gravel rash T14.8XXA – OTHER INJURY OF UNSPECIFIED BODY Active 2019 
REGION, INITIAL ENCOUNTER 
Motorcycle accident V29.9XXA – MOTORCYCLE RIDER (DRIVER) Active 2019 
(PASSENGER) INJURED IN UNSPECIFIED TRAFFIC 
ACCIDENT, INITIAL ENCOUNTER 

Past Medical History :   
PMH: Low testosterone 
Old records: Medications: testosterone, HGH, anastrozole 

Allergies 
No Known Drug Allergies

Home Medications 
Docusate Sodium, 100 milligram orally 2 times per day 
HYDROcodone-acetaminophen 5 mg-325 mg, 1-2 tablet orally every 6 hours PRN 
Ondansetron Oral Disintegrating Tablet, 4 milligram orally 4 times per day PRN nausea and vomiting(Duration: 3 days) 

Social History : no tobacco use, occasionally drinks alcohol 

Tobacco Use 
None Reported : TOBACCO HISTORY Last Documented By: KATIE MOORE, RN on  02:42 

Recreational Drug Use 
None Reported : RECREATIONAL DRUG HISTORY Last Documented By: KATIE MOORE, RN on  02:42 

Review Of Systems 

ROS: 

rx All systems reviewed and found to be negative except those mentioned in the history of present illness.

Vital Signs 

Most Recent Set of Vitals: 
BP: 145/69  03:00 
Pulse: 83  03:00 
Resp: 16  03:00 
02 Sat: 98%(01/m)(Room Air) 08/12/2019 03:00 
Calculated BMI: 29 

Vitals: Pulse Ox [This section may be copied as needed] 

02 Source : Room air 02 Delivery : 02 L/min FiO2 % 

Pulse Ox Reading: 100 % Interpretation: nomal Date/Time: 

Physical Exam 

GENERAL 
General: Awake, alert, oriented x3, cooperative, and in no apparent distress.
Head: Normocephalic and atraumatic.
Eyes: Pupils equal and reactive to light, extraocular movements intact, eyes artaumatic.
ENT: Nose is clear, oropharynx clear, airway patent and protected.
Neck: no JVD, trachea midline, no c-spine tenderness 
Pulmonary: Clear to auscultation bilaterally, no respiratory distress.
Cardiac: Regular rate and rhythm, heart sounds normal.
GI: Abdomen soft, nontender, nondistended.
Musculoskeletal: Back nontender.Soft tissue swelling about the left ankle, with tenderness to palpation, but 
neurovascularly intact distally, the remainder of the extremities are without tenderness to palpation and with range of 
motion normal.Peripheral pulses intact throughout and symmetric.
Neurologic: Moves all extremities normally with 5/5 strength throughout, sensation intact throughout to light touch, 
speech and coordination normal.GCS 15.
Skin: Abrasions consistent with road rash on the right lateral abdomen, left thigh, left knee, left leg.

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Diagnostic Studies [This section may be copied as needed] 

Date / Time: Study: three views of the left ankle, And four views the left knee -both 
interpreted by me ankle: Oblique comminuted fracture of distal fibula at and above the level of the mortise, widening of the mortise medially to 7.5 mm, no apparent tibial fracture, no dislocation.

Knee: No fracture, dislocation, or bony lesion visualized.

Progress [This section may be copied as needed] 
Date / Time: 

Progress Notes: 
I called and spoke with Dr. , orthopedic surgeon on duty at this time.Findings were discussed.He reviewed the  patient’s x-rays.He feels the patient’s ankle fracture will require surgery, however, the patient may be discharged home in a splint.He will see the patient in his office to arrange operative repair.

Splinting: Under my direct supervision the patient’s left lower extremity was placed in a fiberglass short-leg 2 part U+L splint, and  was neurovascularly intact distally following its application.The patient was provided with crutches, in instructed in their use. Patient tolerated the procedure well.No complications.

Medical Decision Making (MDM) :   
patient presents following motorcycle crash, and has road rash, and pain and swelling of the left ankle.X-rays demonstrate an unstable ankle fracture but without dislocation.There is no indication for ED closed reduction or emergent surgery, however, this will require operative repair as an outpatient, according to orthopedic consultant.Splint was placed.

Differential diagnosis includes significant intracranial injury, C-spine fracture, focal neurologic deficit, altered mental status, significant injury to the chest, abdomen, pelvis, I do not believe any above was present.Diagnoses considered not limited to those discussed here.

Plan: Follow up with Orthopedic surgery in the next 3-5 days.Norco, Colace, Zofran p.r.n..May also use over-the-counter ibuprofen.Strict return precautions given and discussed.Wound care as discussed.

ED Diagnosis (Current Problem List) :   
Problem Associated ICD-10-CM Code Status Onset 
Closed fracture of shaft of left fibula 
582.432A- DISPLACED OBLIQUE FRACTURE OF SHAFT Active 
OF LEFT FIBULA, INITIAL ENCOUNTER FOR CLOSED 
FRACTURE 
Gravel rash T14.8)0(A – OTHER INJURY OF UNSPECIFIED BODY Active  
REGION, INITIAL ENCOUNTER 
Motorcycle accident V29.9XXA – MOTORCYCLE RIDER (DRIVER) Active  
(PASSENGER) INJURED IN UNSPECIFIED TRAFFIC 
ACCIDENT, INITIAL ENCOUNTER 

Rx given: 
Norco, Colace, Zofran 

Disposition 

Disposition Decision Date/Time: 

# D/C from ED to: Home 

# Condition at D/C: stable

CPT codes:

99283
29515-LT Application of short leg splint

The physician applies a short leg splint from calf to foot. A short leg splint is used to immobilize the ankle. The physician wraps cotton bandaging from just below the knee to the toes. Plaster strips or fiberglass splinting material are applied to the posterior of the calf, around the heel, and along the bottom of the foot to the toes. The splint material is allowed to dry. The splint is secured into place with an Ace wrap.