Orthopedic Coding Alert

Question: A primary-care physician (PCP) referred a patient to our practice after he had performed and read the patient's x-ray and diagnosed a distal radius fracture (813.40-813.43). When I saw the patient, I billed a consultation (99241-99245) and fracture care (25600-25620), but my office manager said I can't report both. Is this accurate? Also, sometimes in the hospital, the emergency department physician will diagnose a patient's fracture, then ask me to perform fracture care. Can I bill a consult (99251-99255) and fracture care in this scenario?

Texas Subscriber

Answer: CPT defines a consultation as "a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is being requested by another physician or appropriate source." Therefore, regarding your first question, you must establish whether the PCP requested your opinion or advice on treating the fracture, or whether he simply transferred care to you.

If you performed the three criteria for reporting a consultation (request for opinion, rendering the opinion, and reporting back to the original physician), you can report the consultation and the fracture care. 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 consultation code.

As for your hospital visit, ask yourself this question before reporting both the fracture care and the consult: Could you dictate a separate procedure note for the non-manipulative fracture care? If so, you can probably report both services. However, most coding and compliance experts agree that unless the physicians evaluate a separate injury during the consult, their documentation cannot support reporting both services.