Orthopedic Coding Alert

Question: After an office evaluation and management (E/M) service for a patient with an injured leg, the orthopedist makes the diagnosis of non-displaced left distal fibular fracture, which she treats closed with application of a short leg cast. Notes indicate that the E/M included a detailed history and examination, and moderate-complexity medical decision making (MDM). She also performed a complete X-ray of the ankle before deciding on surgery. How should I code this encounter?

Massachusetts Subscriber

Answer: To file the most accurate claim possible, you’ll need a bit more info from the operative report or the performing surgeon. We’ll look at the three main CPT^® coding elements of this claim; put them together and you’ll file the cleanest claim possible.

Procedure: For the surgery, you’re going to choose between 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation) and 27788 (… with manipulation), depending on whether or not the surgeon used manipulation during the repair.

X-ray: For the complete ankle X-ray, report 73610 (Radiologic examination, ankle; complete, minimum of 3 views).

E/M: Provided the E/M service is significant, separate, and led the provider to decide on surgery, you can file a code for the E/M separately. Your question does not indicate whether the patient was new or established, however. Go back and check the notes on the E/M; then, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) for a new patient; for an established patient, report 99214 (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 detailed history; A detailed examination; Medical decision making of moderate complexity …) for the E/M.

Modifier(s): Since either code you choose for the procedure carries a global period of 90 days, you’ll append modifier 57 (Decision for surgery) to the E/M code to show that the surgeon performed a significant, separately identifiable E/M that led to the surgery. Don’t 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 your E/M code in this case; remember, modifier 25 is for “minor” procedures (surgeries with global periods less than 90 days).

If you are only providing the interpretation and report of the X-ray and don’t own the equipment, you’ll need to tag modifier 26 (Professional component) to 73610. You might also need to append modifier LT (Left side) or RT (Right side) to the procedure and/or X-ray code(s), depending on payer preference. If you have any doubt as to the payer’s stance on laterality modifiers, call before completing the claim.