Orthopedic Coding Alert

Question: Encounter notes indicate that the provider performed osteotomies on the distal third of the radius and ulna after a level-four new patient office evaluation and management (E/M) service. The osteotomies did not involve realignment on an intramedullary rod. I reported 25350 and 25360 for the osteotomies and 99204-25 for the E/M and the payer denied the claim. How should I report for this encounter upon resubmission?

Massachusetts Subscriber

Answer: You’ll report two codes for this encounter: a single code for both osteotomies and an E/M code. Also, your modifier choice was incorrect.

On the claim, report:

• 25365 (Osteotomy; radius AND ulna) for the osteotomies
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99204 to show that a separate, significantly identifiable E/M service occurred before the osteotomies.

Explanation: You’d report the codes you chose — 25350 (Osteotomy, radius; distal third) and 25360 (… ulna) — for single-site osteotomies. When the osteotomies are both performed at the same session, and are the same type of osteotomy, opt for 25365.

Further, the choice of 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) was incorrect because the global period for 25365 is major (90 days), meaning you should use modifier 57 for any E/M associated with that code. Modifier 25 is for use on E/M services that accompany procedures with a minor (0- or 10-day) global.