Reader Question: Fractured Coccyx

Question: If someone comes in with a fractured coccyx, should we enter the specific procedure code and the evaluation and management (E/M) code, or will the ICD-9 code and the E/M code suffice?

Roslyn Weinstein
Beth Israel Medical Center, New York

Answer: For outpatient encounters, it is important to understand that CPT codes communicate the services provided to the patient and that ICD-9 codes communicate the reason (i.e., medical necessity) the services were performed.

Under APCs, all provided services should be captured and reported with the appropriate CPT code for hospitals to receive full reimbursement. At the same time, to be in compliance, never report a CPT code unless the services represented actually are performed and documented in the patients medical record.

In the example given, if a patient presents with a fractured coccyx, 805.6 (fracture of sacrum and coccyx, closed) would be reported as the diagnosis. The CPT code(s) reported would depend on the services rendered. For instance, if both an E/M service and closed treatment of the coccygeal fracture were separately performed and documented, both the E/M code with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and CPT code 27200 could be reported. If no fracture treatment was provided, only the E/M visit code should be reported.

Source for this Reader Question is Laura Siniscalchi, CCS, CCS-P, CPC, education coordinator at Beth Israel Deaconess Medical Center in Boston.

- Published on 2000-09-01