Question:
A parent brings her 14-year-old son to the ED with an injured right finger he suffered during a skiing accident. The physician diagnoses a closed metacarpal fracture, which he resets using manipulation and places in a plaster cast. He tells the parent to follow up with an orthopedist for continuing care. Notes indicate a level-three pre-procedure E/M service. What modifier should I append to the E/M code?North Carolina Subscriber
Answer:
Many private payers (and Medicare) want you to append modifier 57 (
Decision for surgery) to the E/M service code each time the physician provides definitive fracture care and an E/M during the same encounter.
For these payers, report the following:
- 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 coding the procedure only and not coding for the follow-up care
- 99283 (Emergency Department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity
for the E/M service - Modifier 57 appended to 99283 to show that the E/M and fracture care were separate services and that the E/M service resulted in the initial decision to perform the procedure 815.00 (Fracture of metacarpal bone[s]; closed; metacarpal bone[s], site unspecified) appended to 26605 and 99283 to represent the patient's injury; and
E003.2 (Activities involving ice and snow; Snow [alpine][downhill] skiing, snow boarding, sledding, tobogganing and snow tubing) appended to 26605 and 99283 to document the activity that led to the injury.
However:
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 the E/M code when billed in conjunction with certain fracture care codes.
-- Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.