September Annals Audio up and running!

September Annals Audio is posted here, check it out:

Highlights —

-Ketamine v morphine for pain
-Is droperidol safe for agitation… the unsurprising answer
-Opiates in the ED: 1) the patient perspective, 2) ED prescribing patterns
-Contrast-induced kidney injury, and one year outcomes
-Ebola triage and decision aid, transport of Ebola patients, and ED Ebola processes

and, as always, much much more.

Until next time, email any time at,


August Annals Audio is posted!

The August episode of the Annals Audio/Podcast is now available here. Highlights include:

-Color coding pediatric resuscitation syringes: a new (i.e. better) way
-Oral contrast in peds abdominal trauma: worthwhile or worthless?
-Antibiotics only for peds appendicitis: the literature
-Vital signs at handoff — “Forgot to mention: he’s hypotensive…”
-H Pylori testing in the ED
-Tackling smoking in the ED, a RCT: it worked
-QT prolongation in antipsychotic overdose: less common than we thought?

Check it out and email anytime at!

Talk soon,

Annals Audio for July is up!

July podcast/audio is now posted, check it out. Highlights:

-Self-care barriers for CHF patients: are most ED visits inevitable?
-Communication between doctor and patient surrounding ACS admissions: there isn’t much…
-Is the Golden Hour still golden?
-Boston bombings: preventing future IT problems that affected response
-HIV ‘care continuum': is it being respected in the ED?

And much much more. Email any time at,


June podcast!

Posted and available, right here. Highlights:

-Children who bounce back with meningitis or sepsis: a review

-Rapid administration of ketamine, quick-on/quick-off?

-ED use among patient-centered medical home participants

-ED use among young adults after the Affordable Care Act

-Intercepting wrong-patients orders in a CPOE system

Plus snapshot reviews, a game changing Steve Green editorial, and more….

Email any time at,


Fight Bite and Coding

Fight Bite PicLaterality and Specificity Are Needed to Correctly Code Hand Injuries Using ICD-10

By David B. Chauvin, DO, FACEP

Dr. Smith sees a 23-year-old male with a right hand injury. The patient was at a bar last night and hit another patron in the mouth. He has pain at the right 5th metacarpal phalangeal (MCP) joint and a small laceration. History is otherwise negative. Physical exam reveals a 1 cm laceration over the right 5th MCP, no surrounding redness or discharge, but the joint is tender with passive range of motion. Tetanus is updated and IV antibiotics given. X-ray shows a boxer’s fracture with displacement and no foreign body. Orthopedics is consulted.

Dr. Smith records a diagnosis of “fight bite.” Orthopedics decides to take the patient to the operating room for irrigation of the wound and repair of the open fracture.

The transition to ICD-10 will occur on 10-1-15. ICD-10 requires a higher degree of specificity to correctly code orthopedic and hand injures. In this example, it would be important to document where and how the injury occurred and whether alcohol was a contributing factor. The precise location of the fracture, including which hand, which finger, and which phalange are all needed for accurate coding of the encounter.

In this example, it would be better for the ED physician to diagnose “open, displaced fracture of right 5th metacarpal bone.”

The ED coder would assign the following ICD-10 diagnosis codes:

S62.336B  (Displaced fracture of the neck of fifth metacarpal bone, right hand, initial visit for open fracture)

S61.451A  (Open bite of right hand, initial encounter) to describe the mechanism of injury.

For the Evaluation & Management service, the coder would also assign a CPT code such as 99284.

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page at

ICD-10 What To Do Now

chauvinBy David B. Chauvin, DO, FACEP

With passage of the Medicare Access and CHIP Reauthorization Act of 2015 it is official that ICD-10 CM will become a reality October 1st 2015. This is a huge deal for your billing company, hospital, payer contracts and you.

ICD-10 CM is an updated and expanded diagnosis coding system that will replace ICD-9.
At the very least, every clinician working in the ED will need to know how to document in an ICD-10 CM friendly manner. ICD-10 CM requires more specificity and details than ICD-9. Trauma and injuries make up a significant percentage of the new ICD-10 CM codes with laterality (left right upper and lower) now essential elements of the chart.
ICD-10 CM is ultimately tied to hospital and professional reimbursement; hence you also may be at risk for increased denials, charts deemed incomplete and an unhappy hospital CEO.

Here is a list of things you need to do now:

Identify your current systems and work processes that use ICD-9.
Diagnosis ICD coding is not just used for the final diagnoses, but is also used to justify ED testing such as CT scans, EKGs and lab tests. How does your current documentation system assign codes to diagnostics that you ordered? Although ED docs rarely order outpatient testing, be sure that your order form includes ICD-10 codes.

ED Professional Billing
Who is doing your professional billing? How are they going to implement ICD-10 CM? How are they conducting their internal and external validation testing?

Get to know your coder
Coder feedback will be critical. Try to develop a professional rapport with your coding staff such that they feel uninhibited to ask clarifying questions.  Now might be a good time to buy the coding staff a large box of cookies.

ED Nurse documentation
Can you make your nurse triage note and nursing documentation more ICD-10 friendly? Consider prompts for external cause of injury, geographic location of injury and mechanism of injury. Documentation of laterality, left right and upper and lower now needs to be clearly documented.

Physician Productivity
Yes, once again physician productivity may go down. Perhaps your group is on the tipping point for the employment of scribes or extenders. ICD-10 may make such a decision more clear cut.

Internal Audit
Randomly select 10-20 charts and ask your coders to code the charts via ICD-10 CM. This should provide a baseline to allow for individual provider education.

Resource Help
To help Emergency Physicians prepare for this change to ICD10, ACEP will be providing ICD-10 documentation tips and insights for the busy ED physician. You can find these resources in several locations, including:

ACEP’s monthly magazine, The Official Voice of Emergency Medicine, is planning articles in the months leading up to October 2015. Written by physicians, for physicians, news about ICD-10 will be specific to EM practice.

ACEP Website
ACEP’s home page will include the latest updates, and an ongoing list of resources will be added to the Reimbursement section of the site. Currently, you can find clinical examples, an information paper and an ICD-10-CM manual.

EM Today Newsletter
ACEP partners with Bulletin Health Care to bring the latest health care news each morning from Monday through Friday. Included within EM Today is news and events specific to ACEP. Updates and links to the latest articles on ICD-10 will be included in this newsletter.

Weekend Review
Each Saturday, a roundup of the week is delivered with ACEP partner, Multi-View. Also sprinkled throughout the newsletter are briefs specific to ACEP and emergency medicine. ICD-10 news will be included here.

Social Media
ACEP has an active following on social media. Here are the outlets for information about ICD-10 to be disseminated through ACEP’s membership.