Orthopedic Coding Alert

Question: Our orthopedist completed a reduction in the office for a dislocation, placed a splint, and took postreduction films. Then, he completed another reduction of the same area, placed a splint, and took post-reduction films again. This was during the same office visit, so I assume the first reduction was unsuccessful. How do I report these services?

North Carolina Subscriber

Answer: Correct coding depends on the circumstances, so verify details before reporting this case, particularly the reason for the second reduction. It looks like the dislocation wasn’t fully aligned after the first reduction and your physician saw this upon reading the postreduction films.

If this is the case, report the reduction once. If the same x-ray code applies to both sets of films, report the appropriate code twice and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to the second line item.