ED Coding and Reimbursement Alert

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:

• 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; and
• ICD-10 S52.531 (Colles’ fracture of right radius) (appended to 99284, 25605 and 73100 to represent the patient’s injury.

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.