Medicare Compliance & Reimbursement

Question: A parent brings her 14-year-old son to the emergency department with an injured right finger he suffered during a skiing accident. The physician diagnoses a closed metacarpal fracture, which he resets using manipulation and places in a plaster cast. He tells the parent to follow up with an orthopedist for continuing care. Notes indicate a level-three pre-procedure E/M service. What modifier should I append to the E/M code?

Answer: Many private payers (and Medicare) want you to append modifier 57 (Decision for surgery) to the E/M service code each time the physician provides definitive fracture care and an E/M during the same encounter. For these payers, report the following:

26605 (Closed treatment of metacarpal fracture, single; with manipulation, each bone) for the fracture care

Modifier 54 (Surgical care only) appended to 26605 to show that you are coding the procedure only and not coding for the follow-up care 99283 (Emergency Department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) for the E/M service

Modifier 57 appended to 99283 to show that the E/M and fracture care were separate services and that the E/M service resulted in the initial decision to perform the procedure 815.00 (Fracture of metacarpal bone[s]; closed; metacarpal bone[s], site unspecified) appended to 26605 and 99283 to represent the patient's injury; and]

E003.2 (Activities involving ice and snow; Snow [alpine][downhill] skiing, snow boarding, sledding, tobogganing and snow tubing) appended to 26605 and 99283 to document the activity that led to the injury.

However: Some payers will prefer that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code when billed in conjunction with certain fracture care codes.