ED Coding and Reimbursement Alert

Question: A 3-year-old child presented to our ED with a history of falling off a chair and injuring his right wrist. After performing a physical exam, the physician orders a forearm x-ray, which shows a buckle fracture of the right wrist. The physician temporarily protects the injury with a forearm splint and refers the patient to an orthopedic surgeon for restorative treatment. Can I code for the splinting?

North Carolina Subscriber

Answer: Because the physician provides only the initial splinting without restorative treatment, you can code for the forearm splinting with 29125 (Application of short arm splint [forearm to hand]; static).

If the physician instead performed the definitive fracture care, you might report 25600 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) with modifier 54 (Surgical care only) appended to show that you are not coding for any follow-up care.

In either situation, you can still code for the physician's x-ray services with 73090 (Radiologic examination; forearm, 2 views). Remember to append modifier 26 (Professional component) to 73090 to show that you are only coding for the physician's interpretation of the x-ray.

In this scenario, it is almost 100 percent certain that the ED physician performed a separate E/M service in addition to the fracture care.

CPT indicates you can report further significant, identifiable services performed at the time of the cast/ splint application. A fall from a chair may involve checking for possible head injury and any other wounds, and will probably require an expanded problem focused history and exam, which could support 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) or higher.

Best bet: If you identify a separate ED E/M service, choose a code based on encounter specifics. Remember to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the day of the procedure or other service) to the E/M code you report to show that the E/M and fracture care were separate services.