ED Coding and Reimbursement Alert

Question: A patient reports to the emergency department (ED) after slipping and falling off the icy stairs on their front porch. They report left shoulder pain at 8 on a scale of 10. Upon physical examination, the ED physician notes swelling and limited left shoulder movement. An X-ray confirms a closed fracture of the left clavicle. Without any surgical incisions, the ED physician manually moves the clavicle back into alignment, places the patient in a figure-of-eight brace, and prescribes pain medication. How should I report this encounter? Is the shoulder repair part of the evaluation and management (E/M) service?

Utah Subscriber

Answer: The ED physician performed closed treatment on the clavicle, which is separately reportable from the E/M.

On the claim, report 23505 (Closed treatment of clavicular fracture; with manipulation) for the shoulder repair with modifier LT (Left side) appended to indicate laterality. Then, choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set the for the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) attached to show that the shoulder treatment and E/M were separate, significantly identifiable services.

Finally, append ICD-10-CM codes S42.002A (Fracture of unspecified part of left clavicle, initial encounter for closed fracture) and W00.1XXA (Fall from stairs and steps due to ice and snow, initial encounter) to 23505 and the ED E/M code to represent the patient’s injury and the cause of the patient’s injury, respectively.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC