Pediatric Coding Alert

Treating a child with a possible fracture can require a lot of time. The pediatrician may not immediately know if a fracture is present, and may expend almost the same time and effort whether it exists or not. The fracture repair codes -- which pay very well -- apply only if there is a fracture. If no fracture exists, payment may be less, but you can still maximize reimbursement with careful coding of the documented services.   Billing With X-rays   A 10-year-old slips while playing with friends, twisting an ankle. The ankle is very swollen when the child is seen that afternoon. The pediatrician conducts an evaluation to be sure there are no other injuries and sends the patient for an x-ray.
The radiologist calls to report that the x-ray is negative, and the patient returns to the office. The pediatrician prescribes ice packs and Tylenol, and tells the patient to return as needed. In this case, bill for an E/M visit (99212-99215, established patient) and any subsequent visits. Use diagnosis 845.00 (sprains and strains of ankle and foot; ankle; unspecified site).
Pediatricians without x-ray equipment in the office would probably talk to the parent on the phone after the radiologist reads the x-rays. Because you cannot use phone time to upcode the level of office visit (it is not face-to-face), you should provide most of the education for care in your office before sending the child to the radiology office (i.e., tell the parent how to care for the injured ankle while he or she is still in your office, prior to the x-ray). Such counseling time, if more than 50 percent of the total encounter time, can be used to upcode the E/M level. If the x-ray is positive, you will likely (but not necessarily) refer the child to an orthopedist.
Bill the fracture repair codes when treating a fracture. For example, a 7-year-old child presents with what you suspect may be a distal radial fracture sustained during a volleyball game. You examine the arm, determine if there are any other injuries and send the patient for an x-ray. 
The radiologist calls, stating that there is a buckle fracture. When the patient returns to your office, treatment consists of casting -- for which you bill 25600 (closed treatment of distal radial fracture) -- and recommending ibuprofen. Use diagnosis code 813.42 (fracture of radius and ulna; lower end, closed; other fractures of distal end of radius [alone]).
In addition to the fracture repair code, you may bill an E/M service because you provided a significant, separately identifiable service in addition to the fracture repair. Although you saw the child twice -- before and after the x-ray -- report only one E/M code, taking into [...]