ED Coding and Reimbursement Alert

Question: A 36 year old patient presents to the ED with pain and inability to ambulate due to pain in his right lower extremity after a fall. The ED physician notes swelling and ecchymoses just above the patient's right ankle during a detailed exam (notes indicate a detailed history as well). He orders the patient to be medicated with intravenous Dilaudid and orders an x-ray of the ankle and tibia-fibula. The x-ray shows a moderately angulated fracture of the distal portion of the tibial shaft. After the patient receives moderate sedation, the physician manipulates the fracture and re-aligns the bones. A post reduction x-ray shows the bones to be well aligned, so the physician places the patient in a cast with instructions to follow up with an orthopedist. Notes indicate 22 minutes of moderate sedation time with a qualified independent observer monitoring the patient.

What is the coding combination for this scenario?

Michigan Subscriber

Answer: Properly reporting this encounter will require several modifiers. On the claim, report the following:

• 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction) for the fracture care
• Modifier 54 (Surgical care only) appended to 27752 to show that you are only coding for the fracture care, not the restorative care
• 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 service
• Modifier 57 (Decision for surgery) appended to 99284 to show that it was a separate service from the fracture care
• 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intraservice time) for the moderate sedation
• 823.20 (Fracture of tibia and fibula; shaft, closed; tibia alone) appended to 27752, 99284 and 99144 to represent the patient's injury.