Orthopedic Coding Alert

Question: A new patient presents to the orthopedist after falling from a hotel balcony. The patient complains of pain in their right pectoral and rib area. During the examination, the orthopedist notes that the area is tender to the touch and slightly swollen. The patient rates the pain as 6 on a scale of 10. The orthopedist orders a four-view X-ray including posteroanterior chest, which confirms a right chest contusion and bruised ribs. The physician wraps the patient’s ribs and pectoral area, prescribes rest and nonsteroidal anti-inflammatory drugs (NSAIDs), and sends the patient home. How should I report this encounter? Can I code separately for the orthopedist’s treatment of the chest/ribs?

AAPC Forum Subscriber

Answer: Your orthopedist’s treatment of the patient’s ribs isn’t separately reportable. You can, however, consider the treatment when deciding on the overall level of the office/ inpatient evaluation service. In addition to the physical and exam, you should factor the wrap and the physician’s advice to the patient when deciding on an E/M code.

On the claim, you should report:

• 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.) code set
• 71111 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) for the X-rays
• Modifier RT (Right side) appended to 71111 to indicate laterality
• S20.219A (Contusion of unspecified front wall of thorax, initial encounter) appended to the E/M and 71111 to represent the patient’s rib bruises
• S20.01XA (Contusion of right breast, initial encounter) appended to the E/M and 71111 to represent the patient’s chest bruise
• W13.0XXA (Fall from, out of or through balcony, initial encounter) appended to the E/M and 71111 to represent the cause of the patient’s injuries.