Pediatric Coding Alert

6 answers improve your nursemaid elbow pay

Did you know that you can bill an E/M with CPT 24640 and earn big bucks? If not, you're forfeiting pay you deserve for nursemaid elbow services.

"Many pediatricians are reluctant to charge for treating nursemaid elbow and instead refer the child to an orthopedist," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine in Medford, N.J. You should, however, encourage your pediatrician to perform and bill for the minor, easily accomplished dislocation work, he says.

"Orthopedists are happy to charge high rates for doing the exact same work that the pediatrician could do," Scott says. Plus, the pediatrician will spend time talking to the parents about treatment and recurrence issues that an orthopedist may overlook. To help you improve your nursemaid elbow reimbursement, coding experts answer six billing questions based on the following scenario:

While crossing a street, a child's mother pulls him out of the way of oncoming traffic. The pull accidentally displaces the boy's elbow. After performing an expanded problem-focused history, an expanded problem-focused examination and low-complexity medical decision-making, the pediatrician reduces the radial head. The physician may also place the child's arm in a sling to provide comfort and stability.

1. Which Codes Should You Use for Manipulation?

You should bill 24640* (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) for the radial head reduction, says Sandra Holman, medical reimbursement specialist at Growing Up Pediatrics in Cornelius, N.C. For the diagnosis, you should assign 832.00 (Dislocation of elbow; closed dislocation; elbow unspecified).

2. Should You Report an E/M Service?

In this example, you should bill 99212-99213 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typical spend 10-15 minutes face-to-face with the patient and/or family) for the pediatrician's elbow examination, Holman says. If the pediatrician does more than evaluate the elbow, such as assessing the patient for a possible head injury, you may report a higher E/M service level, she adds.

"In fact, you should always bill an E/M with 24640," Holman says. Because 24640 is a starred procedure, the code includes the surgical procedure only and contains no pre- and postoperative services. Therefore, you should separately report an E/M for the pediatrician's injury evaluation, which he used to determine the medical necessity of the radial head reduction.

Even if the pediatrician realizes immediately that he must treat the elbow - and reduces it right away to bring relief to the child - the pediatrician must first take a history and perform at least a limited examination of the area, Scott says. Correct coding for the nursemaid scenario so far is 24640, and 99212-99213 with 832.00, which brings us to the next question:

3. Do You Need a Modifier?

Only use a modifier when a payer doesn't reimburse for 24640, 99212-99213. If an insurer bundles the E/M service into the nursemaid reduction, you should attach modifier -57 (Decision for surgery) to E/M code, the American Academy of Pediatrics (AAP) recommends. When a service results in the initial decision to perform the surgery, you may add modifier -57 to the appropriate E/M code level, according to CPT Appendix A - Modifiers.

Code 24640 is a surgical code. So, appending modifier -57 to 99213 in the above example is appropriate. Because some payers, such as Oxford, permit modifier -57 on nonstarred "major" surgery codes only, ask your insurers for coding guidelines.

4. Does 24640 Include the Sling?

 As a fracture/dislocation code, 24640 includes the initial cast, strap or splint application. Radial head subluxations rarely require such materials, Scott says.
But the pediatrician, as in the prior example, may place the child's arm in a sling for his comfort. The fracture/dislocation codes don't include the supply. For payers that accept HCPCS level-II codes, you should bill A4565 (Slings). If an insurer requires CPT codes, you should instead assign nonspecific supply code 99070 (Supplies and materials ...) with the supply's description.

5. Should You Bill for Follow-Up?

Code 24640 contains a 10-day Medicare global period that private payers and Medicaid tend to adopt. "This means that if a patient returns for follow-up within 10 days of the initial visit, you should not charge him for the portion of the visit that deals with the elbow recheck," the AAP states on its Web page "Top Ten Underutilized CPT Codes in Pediatrics" (www.aap.org/visit/top10codes.htm).

6. How Much Revenue Will 24640 Generate?

 The national Physician Fee Schedule assigns 4.85 relative value units to 24640 and 1.39 RVUs to 99213. For a level-three office visit in which the pediatrician performs radial head subluxation, you will charge 6.24 total RVUs, which equates to more than $230.