Orthopedic Coding Alert

Test your knowledge of E/M visits with procedures with this coding quiz

Correctly coding E/Ms and minor procedures performed during a single office visit is a huge cash opportunity. Gauge your coding expertise by determining how you'd code the following three scenarios, and then compare your solutions to our experts'.

Consider These Scenarios

Question 1: Your surgeon treats a child with nursemaid elbow. He takes the history, examines the patient, and adjusts the radial head subluxation into place. Can you report both an E/M and a procedure code?

Question 2: The orthopedic surgeon evaluates a patient with trigger finger and schedules her to return in three weeks for an injection if her condition does not resolve. When she returns, the surgeon discusses her progress with her before he performs the injection. Can he report both an E/M and an injection code?

Question 3: The patient presents with a possible arm fracture with an open wound. The surgeon diagnoses the arm injury as a sprain and then performs a simple repair of the wound. Should he simply report an E/M code, or can he submit the laceration repair code?

Check Your Answers:

Report 2 Codes for Nursemaid Elbow

Answer 1: You can code the nursemaid elbow treatment with 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). In addition, you can report an E/M code (99201-99215). The surgeon doesn't just pop the radial head subluxation into place. He has to take a history, examine the patient and then make the medical decision to treat the injury.

"Because the physician did an evaluation and discussed treatment options, and presuming a history and exam were also documented, you can report both codes," says Annette Grady, CPC, CPC-H, healthcare adviser with Eide Bailly LLP, and an AAPC officer for the National Advisory Board.

Modifier reminder: You should append modifier 57 (Decision for surgery) to the E/M code, Grady says. Although you may not consider the subluxation treatment a "surgery," you should append modifier 57 to your E/M codes when you submit them with a procedure that has a 90-day global period, as 24640 does.

Payer alert: "Some payers may have a policy that does not allow an E/M on the same day as the procedure, but it is still correct coding to report both in  this situation," Grady says.

Include Pre-Injection Chat in 20550

Answer 2: Under these circumstances, you should report only the injection (20550, Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) on the date of service because the procedure was preplanned and the surgeon performed an E/M three weeks before he performed the injection. The surgeon's pre-injection chat with the patient is included in the injection reimbursement.

Caveat: If the surgeon discovers a separate problem at the trigger finger injection visit, he can report an E/M for the unrelated problem.

For example, an established patient with a known diagnosis of trigger finger (727.03) presents for an injection, and the physician evaluates the patient for a completely distinct problem, such as arthritis of the knee.

If the physician has all of the necessary documentation for an E/M code, you would report both 20550, linked to 727.03, and the E/M code 9921x linked to the appropriate arthritis code.

You should 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 to indicate to the carrier that this service was unrelated to the injection and should therefore be reimbursed separately.

Repair and E/M May Go Hand-in-Hand

Answer 3: You should be able to collect for both the repair and the office visit. When a surgeon closes a simple skin wound, most insurers will reimburse over $145 for the repair.

The catch is you have to use the appropriate closure code, such as 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), which the National Physician Fee Schedule pays at $145.53, or 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), which reimburses $153.86.

Bonus: "An office visit can be billed with a repair if all the criteria of an E/M are met and documented at the time of the visit," says Susan Vogelberger, CPC, CPC-H, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

"The same diagnosis code may be used and the modifier 25 would be appended to the E/M code," Vogelberger says.