Orthopedic Coding Alert

Question: An established patient reports to the orthopedist with a right shoulder injury. Notes indicate that after a 52-minute office evaluation and management (E/M) service and a complete right shoulder X-ray, the orthopedist diagnoses a separated right shoulder (our practice owns the X-ray equipment). The surgeon then performs closed treatment of the separated shoulder. During the surgery, they use manipulation. How should I report this encounter?

West Virginia Subscriber

Answer: For this encounter, you should report:

• 23575 (Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement)) for the shoulder treatment.
• 73030 (Radiologic examination, shoulder; complete, minimum of 2 views) for the X-ray.
• Modifier RT (Right side) appended to 23650 and 73030 to indicate laterality.
• 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.) for the E/M.
• Modifier 57 (Decision for surgery) appended to 99215 to show that a significant, separately identifiable E/M service occurred before the surgery.