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
