I would like to know what another ER Professional coder would assign for this ER visit - Our Profee coder assigned 65220-RT and 99281. The procedure has a pre and post e/m included in the procedure code so the pro fee coder feels that you can't assign much of an e/m because of that fact. I feel that this is at least a 99283...Do you have a good way to carve out the two different services so you don't double dip? Please advise..Thxs!
CHIEF COMPLAINT: Right eye irritation, possible foreign body.
HISTORY OF PRESENT ILLNESS: Patient is a 34-year-old white male was working in the Wisner feed lot and was around some welding and hammering at which time a co-worker was hammering a metal on metal object. Patient was turned away at the time and thought that he felt something strike his right eye, possibly a piece of metal. Of note previously in the evening patient had two prior metal shards strike him in the abdomen and in the chest, Minor abrasion sustained from the chest and abdomen wound. Patient was not wearing safety glasses but was wearing his glasses at the time. Patient has chief complaints of right eye irrigation, foreign body sensation, slight blurriness of vision and minor double vision. Patient thought last tetanus shot was over 5 years ago. Patient denies any recent illnesses, infections or fevers. No prior history of right eye trauma.
PAST MEDICAL HISTORY: Total left shoulder in 2004.
FAMILY HISTORY: Hypertension in the patient's mother and father. Patient's
sister is healthy.
SOCIAL HISTORY: Patient smokes approximately one pack of cigarettes per day,
drinks approximately one case of beer per week and has an occasional whiskey
PHYSICAL EXAMINATION: Generally speaking patient is an appropriately dressed
34-year-old white male in mild distress. Vital signs-temperature 98.3, pulse
83, respirations of 20, blood pressure of 120/72. HEENT exam-extraocular
movements intact. Pupils equal round and reactive to light and accommodation. Visual fields equal bilaterally. Vision testing without glasses bilateral is 20/200 with corrective eyewear right eye is 20/25, left eye 20/20. Heart exam-regular rate and rhythm, no murmurs, rubs or gallops appreciated. Chest exam-clear to auscultation bilaterally. No wheezes rales or rhonchi appreciated. Abdomen is nontender, nondistended. Bowel wounds present in all four quadrants. Extremity exam-2+ pulses, no clubbing, cyanosis or edema. Eye exam under room light-visible corneal abrasion, partial thickness, central pupil of right eye. Left eye normal. Possible metal fragment, not definite. Fluorescein eye exam demonstrates pinpoint corneal abrasion central right pupil, no visible foreign body. Patient states that upon administration of numbing agent and Fluorescein that he believes the foreign body dislodged from his eye.
PROCEDURE: Attempt to remove corneal foreign body in right eye.
Patient's right eye was numbed up with Tetracaine one drop applied to both
right and left eye. Fluorescein was applied to the right eye. Very minor
corneal abrasion seen pinpoint right pupil, very minor abrasion under the
right eyelid. Right eye was irrigated with eye solution eye wash kit.
Approximately 20 cc used. A small cotton Q-tip used against cornea in attempt
to clear any remaining debris. Patient tolerated procedure well. Postprocedure no foreign body seen.
ASSESSMENT AND PLAN:
Corneal foreign body. Partial thickness penetration right side for both #1 and #2.
PLAN: Corneal foreign body removed. Regarding corneal abrasion, patient given precaution for further followup regarding signs and symptoms of infection. Patient sent home with Tobramycin ointment to apply bilateral eyes t.i.d. for five days, to followup Monday in the clinic or sooner if any concerns for increasing pain or worsening signs and symptoms of infection or any visual changes.