ED Coding and Reimbursement Alert

Question: If a patient reports to the ED for treatment of a broken bone, can I ever report a separate evaluation and management service as well?


Tennessee Subscriber

Answer: It depends on whether you can prove the physician provided an E/M service significant and separately identifiable from the fracture care. Consider these examples of fracture care coding, one in which the physician provides separate E/M, and one in which the physician only treats the fracture.

Example 1: An ED physician examines a patient who reports with a closed humeral shaft fracture. The patient is also complaining of a headache and chest pain. The physician treats the arm but also conducts a level-four E/M service to determine the cause of the head and chest pain.

In Example 1, the physician provided fracture care and a separate E/M service for problems other than the fracture. On the claim, you should:

- report 24500 (Closed treatment of humeral shaft fracture; without manipulation) for the fracture care.

- attach ICD-9 code 812.21 (Fracture of humerus; shaft of humerus) to 24500 to represent the fracture.

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

- attach 784.0 (Symptoms involving head and neck; headache) to 99284 to represent the patient's headache.

- attach 786.50 (Chest pain, unspecified) to 99284 for the patient's chest pain.

- 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 99284 to show that the E/M and the fracture care were separate.

Exception: If you cannot prove that the physician provided a separate E/M service during fracture care, you should not report an E/M code.
 
Example 2: A patient reports to the ED with a diagnosis of a fractured arm (he's already had an x-ray from his personal physician). The physician casts the arm and sends the patient home. This limited exam is included in the surgical package, and you cannot bill it separately.

In Example 2, you should:

- report 24500 for the fracture care.

- attach ICD-9 code 812.21 to 24500 to represent the fracture.

Remember: While the scenario in Example 2 is possible, the vast majority of fracture care claims will include an EMTALA-required (Emergency Medical Treatment and Labor Act) E/M service as well. Fractured bones are the result of high-energy injuries and connote a degree of severity that usually warrants a thorough E/M exam.

Importantly, from a clinical perspective, fractures can act as distracting injuries and mask other clinically important underlying problems.

Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc., an ED coding and billing company in Stoneham, Mass.