ED Coding and Reimbursement Alert

A nine year-old patient comes in with a history of having fallen off the playground equipment at school. There is an area of tenderness on the distal forearm. Below are some elements of the chart documentation:

PFSH- lives with parents, no medical problems,

ROS - all negative

PE, general exam: vs. normal, HEENT: Nml, CHEST -CTAB, ABD - nml

Extremity- tender area of swelling just proximal to wrist. ROM of wrist is limited by pain, sensory intact to light touch. cap refill <2sec.

X-Ray is ordered-

X-Ray reading by the ED attending: Torus fracture of distal radius.

Treatment: Sugar tong splint is ordered and applied by a cast tech with direct supervision documented by the attending physician including a distal neurovascular check post splinting. A prescription was written for acetaminophen with codeine.

Follow up: Patient and his parents were told to see orthopedist in a week.

How would you report these services?

Answer:  Many groups would report the fracture code 25600 (Closed treatment of distal radius fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation), which has a global surgical period of 90 days and is therefore classified (by Medicare) as a major procedure. If this 9 year old were a Medicare patient, then modifier 57 would be applied to the E/M. Medicare will recognize an E/M for major procedures (global surgical packages of 90days) with a 57, but request the 25 modifier for minor procedures (defined as 0, 10 day global periods).

The documentation also supports an E/M code (likely 99283 or 99284), depending on the extent of the history documented. If the child had not fractured the arm, the visit would easily have justified an E/M code (History, Physical Exam and the MDM points for reading the x-ray). Knowing that the radius was fractured led to the fracture care (definitive-restorative care) which should be an additional service. This child probably does not have Medicare and is governed by the rules of CPT®. Though the fracture care code has a 90 day global period and Medicare directs the use of a modifier 57, some private payers still direct the use of modifier 25.

The area of whether to code an E/M in addition to procedures can be gray and is somewhat determined by the extent of the History and Physical outside of the surgical service. However, in the case of fracture codes (which are really considered surgical procedures by CPT®, even if no manipulation is done), a 57 seems justifiable. The child had a fall, had a head to toe exam screening for other injuries, and that work up lead to the decision to treat the fracture. Given this, you could consider reporting the appropriate ED E/M code with modifier 57.