ED Coding and Reimbursement Alert

Question:  A patient reports to the ED with an injured right finger he suffered during a basketball game. The physician diagnoses a closed metacarpal fracture, which he resets using manipulation and places in a plaster cast. The physician tells the patient to follow up with an orthopedist for continuing care. Notes indicate a level-four pre-procedure E/M service. Do I need to append a modifier to the E/M code?

North Carolina Subscriber

Answer:  Many insurers will want to see modifier 25 on the E/M. However Medicare, and a number of private payers, prefer modifier 57 each time the physician provides definitive fracture care and an E/M in the same encounter since the fracture care codes have a 90 day global and are considered “major procedures”.  For these payers, report the following:

99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; detailed examination; medical decision making of moderate complexity ...) for the E/M service 

Modifier 57 appended to 99284 to show that the E/M and fracture care were separate services

26605 (Closed treatment of metacarpal fracture, single; with manipulation, each bone) for the fracture care

Modifier 54 (Surgical care only) appended to 26605 to show that you are not coding for the follow-up care 

815.00 (Fracture of metacarpal bone[s]; closed; metacarpal bone[s], site unspecified) appended to 26605 and 99284 to represent the patient’s injury.

Be aware:  Some payers will prefer that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to certain fracture care codes. If you are unsure about a private payer’s policy on pre-fracture E/M modifiers, check your contract before filing.