Orthopedic Coding Alert

Question: Notes indicate that the provider performed a decompression fasciotomy on a patient’s lower left leg after a level-two evaluation and management (E/M) service. How should I report this encounter?

Montana Subscriber

Answer: Your answers will depend on the type of fasciotomy and patient status. We’ll tackle each individually:

Fasciotomy: For the patient’s decompression fasciotomy, choose one of the following codes depending on encounter specifics:

• 27600 — Decompression fasciotomy, leg; anterior and/or lateral compartments only
• 27601 — … posterior compartment(s) only
• 27602 — … anterior and/or lateral, and posterior compartment(s).

No matter which of the above codes you choose, you might need to indicate laterality by appending modifier LT (Left side), if you payer requires it.

E/M service: Your question indicates that your provider performed a level-two E/M service for the patient, but you don’t specify whether the patient is new or established. If it is a new patient, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making … ); if the patient is established, report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making … ) instead.

Modifier alert: No matter which E/M code you choose for the patient, be sure to append modifier 57 (Decision for surgery) to the E/M if the surgery is a decompression fasciotomy you’re coding with 27600, 27601, or 27602. You’ll also use modifier 57 if the procedure turns out to be a decompression fasciotomy with debridement, as all of these codes have a global period of 90 days.

If, however, the procedure turns out to be an I&D rather than a decompression fasciotomy, you’d append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code, as these procedures have global periods of 10 days.