Question: A 9-year-old boy reports to the ED with his mother; the mother says the child fell off his skateboard and injured his 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 his arm normally and claiming it really hurt. Physical exam notes indicate that the patient was alert, and his 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 before reducing the fracture and then places the patient’s wrist in a short-arm cast 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 Carolina Subscriber Subscriber
Answer: In this scenario, you can report ED E/M, x-ray interpretation, and fracture care codes; however, don’t forget the modifiers showing you provided a distinctly separate E/M service and are not providing the full global surgical package.
On the claim, report the following:
Modifier 54 tip: ED coders should be very familiar with modifier 54, as it’s 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, not the full global package.
When the ED treatment provided is equal to what an orthopedic surgeon would have provided for the same presentation, you may report fracture care codes. In the same case above, if the emergency physician had not reduced the fracture but only stabilized the injury with a splint before referring to an orthopedist for treatment that involved more definitive care such as placement of a cast, you would report the E/M service along with a splinting code.