Part B Insider (Multispecialty) Coding Alert

Mind your modifiers to ensure payment for several procedures and diagnoses.

Question: A 30-year-old female presented to a rural emergency department (ED) with several injuries after the all-terrain vehicle she was driving overturned. During a levelfive ED E/M service, the physician diagnosed a fractured metacarpal shaft in her left hand and a fractured left femur, and provided closed manipulative treatment for each fracture. How should we code the CPT and ICD-9 codes for this chart?

Answer: Report the most severe fracture first, and make sure that you append a surgical modifier to the treatment codes. For instance:

• 27502 (Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction) for the femur treatment

• 26600 (Closed treatment of metacarpal fracture, single; without manipulation, each bone) for the metacarpal treatment

• Modifier 54 (Surgical care only) appended to 27502 and 26600 to show that you are coding only for the fracture treatment. (If the ED physician is, for some reason, providing all the follow-up care for the patient, then you can leave modifier 54 off the claim.)

• 99285 (Emergency department visit for the evaluation and management of a patient ...) for the E/M

• Modifier 57 (Decision for surgery) or 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), depending on which modifier your payer prefers, appended to 99285 to show that the E/M was a separate service from the fracture care procedure.

Multiple-surgery rules will apply to this claim, so be sure to report the higher-paying code first. Your ICD-9 codes will appear as follows:

• 821.01 (Fracture of other and unspecified parts of femur; shaft or unspecified part, closed; shaft) linked to 27502 and 99285 to represent the patient's femur fracture

• 815.03 (Fracture of metacarpal bone[s]; closed; shaft of metacarpal bone[s]) linked to 26600 and 99285 to represent the patient's metacarpal fracture

• E821.0 (Nontraffic accident involving other off-road motor vehicle; driver of motor vehicle other than motorcycle) linked to 27502, 26600, and 99285 to represent the cause of the patient's injuries.