ED Coding and Reimbursement Alert

Question: Our ED physician reported evaluation and management code 99283-25 and 26720-54 for treatment of a proximal finger fracture. The diagnosis for the former was 959.9, and 816.00 for the latter. If the doctor didn't instruct the patient to follow up with an orthopedist, was he correct with these codes?

Delaware Subscriber

Answer: This scenario raises several issues. Assuming that your physician performed a history and exam that went beyond the localized injury (including, for example, meds, allergies, past medical history, a neurovascular exam, and a screen for other injuries), then you are correct - a moderate-level E/M would apply, such as 99283 (Emergency department visit for the evaluation and management of a patient, which requires an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity). You could further support this assignment if the physician ordered prescription-drug management - such as Percocet - to treat the pain associated with the fracture.
 
The fracture care code 26720 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) is correct if the physician provided definitive care.
 
As for the diagnosis codes, rather than reporting 959.9 (Injury; unspecified site), the more appropriate code would be 959.5 (Injury; finger), because it is more specific. Similarly, the proper fracture code would be 816.01 (Fracture of one or more phalanges of hand; closed; middle or proximal phalanx or phalanges) instead of 816.00 (... unspecified). Once you have the correct ICD-9 codes, you should pair up the first one (959.5) with the E/M service, and the second one (816.01) with CPT fracture code 27620.
 
With regard to modifiers, Medicare rules state that you should append modifier -57 (Decision for surgery) to the E/M code (99283), since the fracture care has a 90-day global period. Modifier -54 (Surgical care only) should go with the fracture code to represent the "surgical component" of the fracture care, because in the emergency department setting, another physician usually provides the follow-up care. Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is not appropriate for either code in this context.