Orthopedic Coding Alert

Question: After a level-four office evaluation and management (E/M) service for an established patient, the surgeon orders a four-view bilateral rib X-ray with posteroanterior chest view. They then perform open treatment on two rib fractures on the right side, and a single rib on the left side. How should I code this encounter?

Michigan Subscriber

Answer: You’ll need help from the appropriate modifier to properly report the left and right rib fracture surgeries. On the claim, you should report:

• 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs) for the right-side rib repairs
• Modifier 50 (Bilateral procedure) appended to 21811 to show that the repair is being performed bilaterally (this will account for the left-side rib repair)
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded for the E/M service.) for the E/M service
• 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 99214 to show that the E/M and the rib repair were significant, separately identifiable services
• 71111 (Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) for the X-rays
• S22.41XA (Multiple fractures of ribs, right side, initial encounter for closed fracture) appended to 21811, 99214, and 71111 to represent the patient’s right-side rib fractures
• S22.32XA (Fracture of one rib, left side, initial encounter for closed fracture) appended to 21811, 99214, and 71111 to represent the patient’s left-side rib fracture.