ED Coding and Reimbursement Alert

Question: A patient reported to the ED complaining of severe elbow pain. After a detailed  history and examination the physician diagnosed an elbow dislocation. The physician used manipu­lation to reduce the joint, prescribed painkillers, and instructed the patient to follow up with his primary care physician (PCP) in two weeks. What is the best CPT^® code for the reduction?

Codify Subscriber

Answer: The AMA’s stance is that the intent of the “with anesthesia” codes is to reflect a formal process performed in the operating room As a result, you would typically use the “without anesthesia” code 24600 (Treatment of closed elbow dislocation; without anesthesia) for care in the ED. In this situation, you might also report the following:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity...) 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 99284 to show that the E/M and the reduction were separate services
• S53.1(Dislocation of elbow unspecified)) appended to the reduction code and 99284 to represent the patient’s injury.

If the physician indicated which radial head (left, right, bilateral) was affected, you would report that instead of the unspecified ICD-10 code.