Orthopedic Coding Alert

Question: Our orthopedic surgeons accept many calls to the emergency department (ED). Should this be billed as a consult?

Oregon Subscriber

Answer: The emergency department service codes (99281-99285) are not limited to ED physicians; however, whenever an ED physician evaluates a patient, he or she will most likely report the services using one of these codes. Because insurance carriers are unlikely to reimburse two physicians for an ED visit on the same day for treatment of the same illness or injury, the orthopedist should report an office or other outpatient consultation code (99241-99245).

The following examples clarify this complicated coding issue:

Scenario A: The ED physician contacts Dr. OS (orthopedic surgeon) to see a patient who has presented to the ED after falling on her outstretched left hand. X-rays show a possible fracture of the distal radius. Dr. OS examines the patient, reviews the x-rays and determines that the patient has a nondisplaced Colles fracture. The patient is placed in a temporary splint. The ED physician discharges the patient with instructions to see Dr. OS in his office in 10 days for casting. Dr. OS dictates a consult report.

Coding A: Dr. OS can report the appropriate-level outpatient consultation code (9924x) along with 29125 for application of the short arm splint. In this case, the consult code is appropriate because another physician requested the services of Dr. OS. Remember, CPT states that the consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.

Scenario B: Dr. OS is on call and paged by the ED to see a patient who fell down the stairs. The patient underwent a right total knee replacement two months prior by a physician in his hometown and is complaining of severe right knee pain. Dr. OS requests x-rays of the patients right knee and advises the ED staff that he will come to the ED to see the patient in about one hour. The ED physician does not see the patient, only Dr. OS does.

Coding B: Dr. OS should report the appropriate code from the emergency department services section (99281-99285). The outpatient consultation codes should not be used because Dr. OS was not requested to see the patient by another physician.

For further clarification, refer to section B3 15506 of the Medicare Carriers Manual.