Orthopedic Coding Alert

Question:  An established patient reports to the orthopedist complaining of severe rib pain in his left flank; this is the initial encounter for this injury. After a level-two evaluation and management (E/M) service the orthopedist decides to take a two-view X-ray, which confirms a pair of left-sided rib fractures. (We use our own X-ray equipment). The orthopedist makes an incision over the injured area, realigns the ribs and stabilizes them using wires. She then irrigates the open area and closes the incision. What is the correct coding for this encounter?

Florida Subscriber

Answer: For this claim, you’ll be able to report a trio of codes with the same ICD-10 code appended to each.

On the claim, report:

• 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs) for the rib repair 
• 71100 (Radiologic examination, ribs, unilateral; 2 views) for the X-ray
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) 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 99212 to show that the E/M was a significant, separate service from the fracture repair and the X-ray
• S22.42-A (Multiple fractures of ribs, left side, initial encounter) appended to 21811, 71100, and 99212 to represent the patient’s injuries.

Closed Tx means E/M: If the provider performs closed treatment of fractured ribs — i.e., she doesn’t make an incision to treat the ribs— it’s considered part of the E/M service, and you should roll any fracture treatment work into the E/M portion of the service instead of reporting a separate rib repair CPT^® code.