Orthopedic Coding Alert

Question: An established patient reported to our office limping badly after falling off the jungle gym at school. Following a level-three evaluation and management (E/M) service, the provider diagnosed a broken left second-digit toe. Without performing any restorative care, the provider “buddy taped” the toe to the great toe. Should I code this as an E/M and then also report a strapping code?

Massachusetts Subscriber

Answer: As long as the provider did not perform any restorative treatment, you should report both services.

Providers often use buddy taping — or taping the affected toe to the adjacent uninjured toe — to treat fractures/sprains of the toes and fingers. Double-check the notes to ensure that the physician performed no restorative treatment. Once you’re sure of that, you can first report 29550 (Strapping; toes) for the buddy taping.

Then, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) for the level-three E/M service you say the physician documented.

Key: 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 99213 to show that the buddy taping and the E/M were separately identifiable services.

Caveat: If the care is more involved than buddy taping, your coding and modifier choice will be different. Let’s say the patient in question has a displaced fracture of the left second-digit toe. Notes indicate that the physician performs a level-three E/M, manipulates the fracture back into alignment, and refers the patient to an orthopedic surgeon for further evaluation. This is an example of restorative care, which is more involved than buddy taping.

On the claim, you should report 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each) for the fracture care. You would still report the appropriate-level E/M service with modifier 25 appended if it is separately identifiable from the fracture care.