ED Coding and Reimbursement Alert

Answer: Your CPT^® coding should be more straightforward than your ICD-10 coding for this encounter.

CPT^® coding: On the claim, report:

• 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) for the E/M
• 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) appended to 99285 to show that a separate and significantly identifiable E/M service preceded the X-ray
• 72100 (Radiologic examination, spine, lumbosacral; 2 or 3 views) for the X-ray
• Modifier 26 (Professional component) appended to 72100 to show that you are only coding for the provider’s interpretation and report, not the X-ray equipment use

ICD-10 coding: Your ICD-10 code choice will depend on which type of fracture the patient suffers from. You can get to S32.05- (Fracture of fifth lumbar vertebra) with the information you provide, but the fracture code needs to be more specific.

Go back and check the notes to see if there is some more detail on the spinal fracture. Then, choose one of the following codes to append to 99284 and 72100:

• S32.050A (Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture)
• S32.051A (Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture)
• S32.052A (Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture)
• S32.058A (Other fracture of fifth lumbar vertebra, initial encounter for closed fracture)

Last resort: If you cannot assign a more specific diagnosis code after you check the notes, opt for S32.059A (Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture).

One more thing: Regardless of your primary diagnosis code choice, append W11.XXXA (Fall on and from ladder, initial encounter) to 99285 and 72100 to indicate how the patient was injured.