Orthopedic Coding Alert

Question: Our physician saw and treated a patient for a scaphoid fracture. The patient, however, fell again and presented with refracture of the scaphoid within the previous fracture's 90-day global period. How should we report this?

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Answer: Because this was a new injury, you should count this as a separate encounter. For your diagnosis, you should report 814.01 (Fracture of carpal bone[s]; closed; navicular [scaphoid] of wrist). If your practice reports E codes to

track the injury's mechanism , use E888.9 (Unspecified fall). As for your E/M service, you should report the level based on your physician's documentation (99211-99215, Office or other outpatient visit for the evaluation and management of an

established patient -). Because this visit takes place during the initial injury's global period, add modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to 9921X

If your physician performs a repeat procedure (such as 25622, Closed treatment of carpal scaphoid [navicular] fracture; without manipulation), add either modifier 76 (Repeat procedure by the same physician) or modifier 77 (Repeat

procedure by another physician). Again, this is because this procedure takes place during the initial injury's global period.