Orthopedic Coding Alert

You Be the Coder:

Can You Make All the Right Coding Moves on This Fx Encounter?

Published on Thu Feb 03, 2022

Question: Notes indicate that the surgeon performed an outpatient evaluation and management (E/M) service for a patient that included a three-view femur X-ray. The final diagnosis was “femoral Fx, proximal end, neck.” Notes on the E/M service indicate that it lasted 52 minutes.

Then the surgeon performed closed treatment of a femoral fracture, proximal end, neck without manipulation. How should I code this encounter?

Georgia Subscriber

Answer: There’s a lot to unpack here. We’ll start with the E/M; then the X-rays; then the surgery; and, finally, the ICD-10 coding.

E/M: Choose from the following options:

If the patient was new, report 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.).

If the patient was established, report 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.).

Append modifier 57 (Decision for surgery) to 99204/99215. The global period for the surgery is 90 days (major), so this is the right modifier for the E/M that led to the decision to operate.

X-rays: Choose from the following options:

Report 73552 (Radiologic examination, femur; minimum 2 views) for the X-rays with modifier RT (Right side) appended to 73552 for X-rays of a right femoral shaft fracture.

Report 73552 for the X-rays with modifier LT (Left side) appended to 73552 for X-rays of a left femoral shaft fracture.

Surgery: Report 27230 (Closed treatment of femoral fracture, proximal end, neck; without manipulation) for the fracture treatment.

Append modifier RT (Right side) to 27230 for treatment of a right femoral shaft fracture.

Append modifier LT (Left side) to 27230 for treatment of a left femoral shaft fracture.

ICD-10: Append one of the following diagnosis codes to 99205/99215, 73552, and 27232:

S72.044A (Nondisplaced fracture of base of neck of right femur, initial encounter for closed fracture)
S72.045A (Nondisplaced fracture of base of neck of right femur, initial encounter for closed fracture)
S72.046A (Nondisplaced fracture of base of neck of unspecified femur, initial encounter for closed fracture).