Orthopedic Coding Alert

Question: A 7-year-old was playing on the monkey bars at a local park when he fell and partially dislocated his elbow. He came to our office, and the provider gently moved the bone and ligament back into place. Four days later, the patient came back complaining of the same problem, and our provider performed the same procedure. How should we code this encounter?

Ohio Subscriber

Answer: Your patient suffered an injury that is variously known as a pulled elbow or a nursemaid’s elbow, though the more technical medical term for it is a radial head subluxation.

Depending on the elbow that was affected, you would code either S53.031- (Nursemaid’s elbow, right elbow) or S53.032- (… left elbow), adding the seventh character “A” to indicate the first visit.

Though you are not required to, per ICD-10 guideline 20.a.1, you should also assign external cause codes for the encounter that describe how and where it occurred. In this scenario, you could add W09.2XXA (Fall on or from jungle gym, initial encounter) and Y92.830 (Public park as the place of occurrence of the external cause), being careful not to sequence the external cause codes as the principal, or first, diagnosis code.

The procedure your provider performed involves supporting the patient’s elbow with one hand while bending the arm upward, then turning the patient’s palm with the elbow bent using the other hand. The procedure is known as a reduction, and you code it with 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation).

In addition to 24640, you will also be able to bill an evaluation and management (E/M) service from 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (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 comprehensive history; A comprehensive examination; Medical decision making of high complexity …), depending on the encounter specifics. Remember to 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 you settle on to show that the E/M and the surgery were separate services.

The second encounter is a little trickier to code, but your modifier choice will again be key. This time, you would append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the appropriate 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional …) through 99215 E/M code, as this is a more extensive procedure. Though the modifier is most often used when a provider divides a procedure into stages, you can also use it when the original procedure was not successful, necessitating a similar, more extensive follow-up procedure to treat the original condition.

You can bill for the second E/M service using the same ICD-10 codes as before, replacing the seventh character, “A,” with the character “D,” indicating that this is a subsequent encounter. Following ICD-10 guideline 20.a.2, you will also need to assign the same seventh character to the external cause codes assigned for the initial encounter.