ED Coding and Reimbursement Alert

Question: A patient presents with a badly injured left ankle. During the course of a level 5 E/M, the ED physician diagnoses a dislocation of the ankle with some diminution of the pulses in the foot. The emergency physician promptly reduces the dislocation to restore blood flow to the foot and calls in an orthopedist, who continues to treat the fracture in the OR. How should I report this scenario?

Missouri Subscriber

Answer: You’ll be able to report an E/M code and a reduction code. However, since the orthopedist performed the definitive fracture care, you should not report a fracture care code27840 (Closed treatment of ankle dislocation, without anesthesia).

On the claim, report the following:

• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key componentswithin the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity…) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99285 to prove that the E/M and reduction were separate services. Of note, Medicare would require modifier -57 (Decision for surgery) in this scenario

• 837.0- (Dislocation of ankle, closed)