Orthopedic Coding Alert

Question: Encounter notes indicate that the orthopedist performed an office evaluation and management (E/M) service for a patient who hurt their ribs playing football. They were hit in the ribs by an opponent’s helmet during a tackle. The surgeon then performed a left-sided four-view rib x-ray with posteroanterior chest exam. After diagnosing two closed rib fractures on the patient’s left side, the surgeon performed open treatment on the pair of ribs. How should I code this encounter? Should I use modifier LT (Left side) on the rib repair code?

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Answer: You won’t need modifier LT for this claim (more on that later). On your claim, report:

• 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs) for the fracture fix
• 71111 (Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) for the X-ray
• A code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set for the E/M, depending on patient status and the specifics of the encounter
• 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) appended to the E/M code to show that it was a significant, separate service
• S22.41XA (Multiple fractures of ribs, right side, initial encounter for closed fracture) for closed fracture appended to 21811, 71111, and the E/M code to represent the patient’s rib fractures
• W21.81XA (Striking against or struck by football helmet, initial encounter) appended to 21811, 71111, and the E/M code to represent the cause of the patient’s rib fractures

Why not LT? You won’t need modifier LT in this instance because the code descriptor for 21811 clearly states “unilateral.” When the code is explicitly unilateral, you don’t need modifiers LT or RT (Right side) to indicate laterality.