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ED Coding and Reimbursement Alert

You Be the Coder:

Modify Your Fracture Care Coding To Provide The Exact Scope Of Services Provided

Published on Wed Apr 16, 2014

Question: A 4-year-old girl reports to the ED with her mother; the mother says the child slipped on the porch steps and injured her right wrist the previous day. The mother says that she noticed some swelling when the injury occurred, and the child seemed to be in significant pain due to the injury. The next morning, however, the mother noticed that the child was still not using her arm normally.  Physical exam notes indicate that the patient was alert, and her wrist was swollen and tender.  

After a level-four ED E/M, the physician orders a two-view wrist x-ray, which shows a displaced fracture of the distal radius and the physician documents a diagnosis of Colles fracture.   The physician performs a hematoma block and reduces the fracture and then places the patient’s wrist in a short-arm cast, immobilizes the wrist and tells the mother to schedule follow-up visits with the orthopedist in 3-5 days. How should I code this scenario?

North Dakota Subscriber

Answer: On this claim, you can report ED E/M, x-ray and fracture care codes – but don’t forget the modifiers or your claim could face red tape.
 
On the claim, report the following:
 
  • 99284 (Emergency department visit for the evaluation an d 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 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and fracture care were separate services. Keep in mind the 25605 is actually a 90 day global procedure in which some payers (including Medicare) will correctly require the -57 modifier rather than the 25.
  • 25605 (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; with
    manipulation    ) for the fracture care
  • Modifier 54 (Surgical care only) appended to 25605 to show that you are only coding for the initial care, not any follow-up visits
  • 73100 (Radiologic examination, wrist, 2 views) for the x-ray if chart documentation supports it
  • Modifier 26 (Professional component) appended to 73100 to show that you are only coding for the physician’s x-ray interpretation services
  • 813.41 (Colles’ fracture, closed) (appended to 99284, 25605 and 73100 to represent the patient’s injury.
  • For ICD-10 S52.531 (Colles’ fracture of the right radius)
Modifier 54 in a nutshell: ED coders should be very familiar with modifier 54, as it will be appended to many procedure codes that you’ll file for your physician’s services. In short, if the CPT® code has follow-up care figured into its work units, you’ll need to append modifier 54 to show that you are only coding for the physician’s surgical services.

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