Orthopedic Coding Alert

Question: After a level three evaluation and management (E/M) service for a new patient with left forearm pain and a magnetic resonance imaging (MRI) of the left arm, the physician diagnoses a bone bruise in the forearm. What exactly is a bone bruise? I didn’t think bones could bruise.

Idaho Subscriber

Answer: Yes, bruises can penetrate the surface of the skin and affect subcutaneous layers all the way down to the bone. According to the University of Rochester Medical Center (URMC), “a bone bruise is a traumatic injury to a bone. It’s less severe than a bone fracture.” Providers might also refer to the injury as a “microfracture” in the encounter notes.

On your claim, you would report:

• 73218 (Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)) for the MRI.
• Modifier LT (Left side) appended to 73218 to indicate laterality, if the payer requires it.
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity … ) for the E/M service.
• 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) appended to 99203 to show that the E/M and MRI were significantly separate services.
• S50.12XA (Contusion of left forearm; initial encounter) appended to 73218 and 99203 to represent the patient’s bone bruise.

More info: “You might think of a black and blue mark on your skin when you hear the word bruise, but bruises can also happen in muscle and bone. This happens when an injury damages small blood vessels and causes blood and fluid to leak into the nearby tissues and blood vessels,” according to URMC.

“Deep inside the bone is an area called the medulla. It contains the bone marrow and fibrous tissue called trabeculae. With a bone fracture, all of the trabeculae in a region of bone have broken. But with a bone bruise, an injury only damages some of these trabeculae,” URMC explains.

Diagnosing these types of injuries is a fairly new phenomenon, with the advent of magnetic resonance imaging (MRI) testing; bone bruises won’t show up on computed tomography (CT) scans.