Pediatric Coding Alert

Question: In the October 2003 Pediatric Coding Alert, you suggest using modifier -57 when coding for nursemaid elbow to payers that reject an E/M service with 24640. In these cases, should I append the modifier to the E/M code or the procedure code? Also, do payers apply a global period to 24640?

Illinois Subscriber

Answer: You should always append modifier -57 (Decision for surgery) to the E/M code, such as 99212-99215 (Office visit for the evaluation and management of an established patient ...), when the pediatrician performs the procedure during the E/M exam. The modifier indicates that the E/M service resulted in the initial decision to perform surgery, for instance radial head reduction (24640, Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation).

In the article "Gain $230 for In-House Radial Head Reduction," the sentence "... you should attach modifier    -57 to 24640, the American Academy of Pediatrics  recommends," should state "to the E/M code," not "to 24640." As the section later describes, "When a service results in the initial decision to perform the surgery, you may add modifier -57 to the appropriate E/M code, according to CPT Appendix A - Modifiers."

The scenario, in which a pediatrician reduces the radial head after performing an expanded problem-focused history, an expanded problem-focused examination, and low-complexity medical decision-making, illustrates proper modifier -57 coding: 24640, 99213-57.

Also, 24640 has a 10-day global period, as the article states on page 76. Although Medicare assigns 24640's surgical package, private payers and Medicaid tend to follow Medicare policy on this issue.