Pediatric Coding Alert

When primary care pediatricians provide fracture care and laceration repair a common situation when children start playing rough winter sports they can ethically maximize reimbursement by selecting the correct combination of E/M and procedure codes. Coding depends on how the pediatrician handles the fracture. If there is no manipulation, as in the case discussed in this article, there is no surgery and the question is whether to code an additional E/M service. In most cases, you should bill the E/M in addition to the global code.

For example, an 8-year-old falls while ice-skating, and the mother brings the child in without an appointment due to extreme wrist pain and a laceration where the arm scraped on a rough patch of ice. The pediatrician examines the child and takes an x-ray that shows a fracture of the radius. Treatment consists of suturing the laceration, making a temporary fiberglass splint, and referring the child to a supplier to be fitted for a removable Velcro splint.

The pediatrician stabilizes the fracture. You have a choice of three code sets:

1. CPT 99213 alone established patient office or other outpatient visit

2. 25600 alone closed treatment of distal radial fracture (e.g., Colles or 
 Smith type) or epiphyseal separation, with or without fracture of ulnar styloid;
 without manipulation

3. 25600 with 99213-25 significant, separately identifiable E/M service by the
 same physician on the same day of the procedure or other service. 
 
The choice depends on reimbursement and ethical issues, says Joel F. Bradley Jr., MD, FAAP, a member of the AMA CPT advisory committee, and a pediatrician at Premier Medical Group, Tennessee.
 
When deciding whether to bill an E/M service in addition to the fracture care, ask whether the office visit is "significant and separately identifiable" and whether the documentation shows that it is. If you only treat the wrist fracture, a separate E/M code may not be justified. But that is unlikely in a primary care situation.
 
If the child, in falling, hit his head on the ice as well, and you examine him for possible head injury in addition to treating the wrist fracture, a separate E/M code is justified. If the child complains of shoulder or back pain and you evaluate that complaint and repair the fracture, you can likewise use a separate E/M code. Do not bill an additional E/M code if all you do is treat the wrist fracture and laceration.
 
Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare Pediatrics in Zanesville, Ohio, says not to bill both codes unless you evaluate an additional injury. "I will use an E/M code if I evaluate some other aspect of the injury," Tuck says, adding that this is usually the case in pediatrics. "Generally, when a child has trauma, it's not just in one place."
 
The E/M is necessary because the pediatrician must determine the method of treatment, says Thomas A. Kent, CPC, CMM, president of Kent Medical Management, Dunkirk, Md. "The full extent of the child's injuries were unknown prior to the office visit," he says. "So the office visit is a significant, separately identifiable E/M service, and it is correct to bill with modifier -25."

The pediatrician should report 12001* (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for repairing the laceration in the arm.
 
The laceration repair is a starred procedure, and therefore a separate E/M code is more justified than with fracture care, Tuck says. Use modifier -25 on the E/M service, whether billing it with 25600 or 12001*.

These are included in the global package for fracture care. If you bill 25600, with or without an E/M service, code the x-ray with 73090 (radiologic examination; forearm, two views), or 73100 ( wrist; two views), or both. If you bill only an E/M service, code the x-ray with 73090, 73100, or both and the casting supplies with 29125 (application of short arm splint [forearm to hand]; static). Code 25600 has a 90-day global period, which covers professional services and the initial splinting supplies. The x-ray is always separately billable.

If you used 25600, you cannot bill for follow-up visits done within the 90-day global period. If you coded only an E/M code, you can. The follow-up visit would probably be reported with 99212 (established patient office or other outpatient visit). You can bill for the follow-up x-ray, even if you billed 25600 initially, as diagnostic x-rays are not included in global fees.

Some coding experts believe you should bill the E/M codes instead of fracture repair, when, as in the case of 25600, the repair is nonsurgical. "If there's a reduction, or with manipulation, you can bill an E/M because you make a decision for surgery," says Richard Haynes, MD, FAAP, a member of the AAP coding and reimbursement committee and a pediatric orthopedist at Shriners Hospital in Houston. Haynes might bill 99213 instead of 25600, which would allow him to bill for casting and follow-up visits as well. "I recommend considering this as an option if there is no reduction of the fracture." Remember, however, that orthopedists often treat a specific injury after the primary care pediatrician has already evaluated the child.
 
Only visits for normal recovery are included in the global period. If infection, failure of the fracture to heal, or other complication occurs, bill these visits outside of the global period with modifier -24 (unrelated E/M service by the same physician during a postoperative period). If you see a patient for an unrelated reason during that period, append modifier -24 to the E/M code for that visit.
 
To summarize, recommended coding for this visit, when the pediatrician evaluates more than just the wrist injury, is:
 

25600

73100 or 73090 or both 

99213-25 

12001.