ED Coding and Reimbursement Alert

Question: The ED physician performs a level-four ED evaluation and management (E/M) service for a patient with right shoulder pain. After a complete shoulder X-ray, the physician diagnoses subluxation of the right shoulder (the hospital owns the X-ray equipment). The physician then performs closed treatment of the separated shoulder. During the surgery, they use manipulation. How should I report this encounter?

Pennsylvania Subscriber

Answer: On the claim, report:

• 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the shoulder treatment.
• Modifier 54 (Surgical care only) appended to 23650 to show that the ED physician won’t be providing follow-up care for the patient.
• 73030 (Radiologic examination, shoulder; complete, minimum of 2 views) for the X-ray.
• Modifier 26 (Professional component) appended to 73030 to show you are only coding for the physician’s services, not the use of the X-ray equipment.
• 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.
• Modifier 57 (Decision for surgery) appended to 99284 to show that the ED E/M led to the decision to operate.

Why not 25? You would append modifier 57 to 99284 because the surgery that follows the E/M has a 90-day global period (major). If the surgery that followed 99284 had a global period of 0 or 10 days (minor), you would have appended modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).