Thread by @brian_hiestand

Last day of ACEP's #RandC19 , starting off with the brilliant Dr. Michael Granovsky's update on ED procedures.

Global periods - 0 day simple lacs, intubation, epistaxis, cerumen removal. 10 days - intermediate lac, abscess. 90 day - fracture care. What does that mean? Less reimbursement for shorter global period, as the follow up care is not bundled in it. #RandC19

Attestations /residents: entire for simple (traditionally < 5minutes), key and critical for more complex procedure. Key and critical is defined by the attending.

Attestations /APPs - no shared services for APP procedures. 85% for Medicare, no way of getting around. #RandC19

Personal opinion: orthopedic procedures are obscenely overvalued. CPR - 5.35 RVU. Patellar dislocation reduction (aka, straighten the leg) - 9.66 RVU. #RandC19

Ultrasound. Don't @ me. You won't make a great deal of $ from it. Doesn't mean that you shouldn't do it right with storage and interpretation, which will mitigate costs (and medicolegally safer). The win is in process time mitigation. #RandC19

ECG. Settled policy that they pay for the first interpretation. Warning - political battles with Cards may cost more than you get back from the ECG interpretation. If you bill for ECG interpretation, it should be up to the standard of the specialist. #RandC19

CPR. The doc does not need to do the compressions, but supervise the resus. Airway, central lines are separately billable. Critical care time? Personal practice - time spent doing ACLS does not count toward CC time, so CC time only if ROSC and subsequent management. #RandC19

Lacerations. Length, location, layers. Location: some places need to be prettier, more functional, or are more delicate than others. Measure your length - 2.6 cm, 5.1 cm, 7.6 cm, 12.6 cm. #RandC19

Lacerations: layers. simple - single layer closure. Intermediate - dual layer, or heavily contaminated. Complex - debridement, extensive undermining, revision of wound edge with dual level closure. #RandC19

Laceration: # of stitches. You don't get paid more for being a human sewing machine. However, document the # of staples / stitches as an act of kindness for the person who has to remove them, so that they are confident they got them all. #RandC19

Laceration - glue. As stated earlier, except for Medicare, simple glue = simple suture. Multiple layer - deep approximation, superficial glue - intermediate complexity (medicare as well). #RandC19

Ocular FB: Conjunctival: superficial vs embedded
Cornea: slit lamp used vs no slit lamp used
Rust ring burr - additional 1.98 RVU

Epistaxis: Anterior vs Posterior [different codes, document specifically]. Limited cautery / packing vs. Extensive [ballon packing]. Commercial ballon product is generally always extensive packing. #RandC19

Fracture care: CPTs are specialty agnostic. EM can bill fracture care if we manipulate the fracture. Splint codes, hematoma block are bundled if we manipulate the fracture. #RandC19

Dislocations: please refer to previous statement on"obscenely over-valued." Strong work, Ortho RUC committee members.

Abscess: simple - pop the zit, paronychia (2.81 RVU)
Complex - loculations, packing, probing. 5.16 RVU (more than a level 5 E&M)
Packing - the evidence pendulum swings predictably on a 5 year cycle. #RandC19

Cardioversion: unnecessarily complex discussion, because of the unfortunate inclusion of "elective" in the coding language. Generally refers to synchronized cardioversion in someone with a pulse.

Osteopathic manipulation is billable in the ED, especially in the #opioidfreeED places. Also trigger point injection. Check your hospital credentialing requirements for trigger point injection before embarking... #RandC19

Back to Ultrasound: medical necessity, interpretation, and image retention. Otherwise, you can't report the code.
Ultrasound guided procedures - LP and pericardiocentesis have separate codes. Many other procedures have bundled (thoracentesis with / without US).#RandC19

Personal opinion - Butterfly users - I would a ) really run your probe by Clinical Engineering before hand (permission vs. forgiveness is not always a great strategy) and figure out HIPAA compliant image storage if you want to code.

Digital blocks are considered local - bundled most of the time. Other regional blocks are separately reportable for fracture care or other procedures. #RandC19

@threadreaderapp can you please unroll?