ED Coding and Reimbursement Alert

Editors Note: The coding advice this month has been provided by Susan Stradley, CPC, CCS-P, a health management consultant with Elliott, Davis and Company, in Augusta, GA, and a former hospital and ED coder, and Garnet Dunston, CPC, MPC, national secretary of the American Academy of Professional Coders Advisory Board.

Question: Our ED does a lot of fracture care, including casting and reductions. Since most of our patients will follow up somewhere else, we will append the -54 modifier to the codes. We also charge an E/M code with the fracture care and use the -57 modifier on the E/M (usually 99282). Is this appropriate coding? Or, would the -25 modifier be more appropriate? We do feel that we should bill an E/M service since these patients do not come to see us for treatment of a fracture, but for an evaluation of an injury. It is only after this evaluation that a need for restorative treatment is determined. Our unique situation is that we are at the base of a ski area and that has allowed us to become quite comfortable with dealing with these fractures. In most places, the E/M would be done by the ED physician and the fracture care by the orthopedist. In our situation, both of these services are being performed by the same physician.

Bernard Riberdy, MD, Vail Valley
Emergency Physicians
Breckenridge, CO

Answer: In most cases, the -25 modifier (significant, separately identifiable procedure or service on the same day) would be more appropriate, states Dunston. Although, orthopedic services are covered under the surgery section of CPT, a decision to cast or reduce a fracture is not necessarily a decision for surgery. CPT doesnt really make the designation, but HCFA (the Health Care Financing Administration) has always held that modifier
-57 (service results in a decision for surgery) should be used for major surgery alone, she says. Only if the patient presented with a complicated fracture that required the services of an orthopedic surgeon to reduce the facture, would modifier -57 be appropriate, Dunston feels. Even then, the surgeon, not the ED physician, would use the -57 modifier on his or her E/M code (e.g., a consult code).

In most cases, the -25 modifier should be added to the E/M charged by the ED physician to indicate the exam that led to the orthopedic service. The -54 modifier (surgical care only) would be appended to the orthopedic code to indicate that another physician will perform follow-up on the patient, states Stradley.

Note: For more information on using orthopedic codes, see the story, Use Orthopedic Codes Plus -54 Modifier to Get Paid for ED Fracture Care, on page 3 of the December 1998 issue of ED Coding Alert.