Pediatric Coding Alert

Question: A 4-year-old boy presented with a dislocated right elbow. After examination, the pediatrician confirms the dislocation and gently moved the bone and ligaments back into place. How do I code this encounter. Since the procedure was performed same-day, does that mean I should append modifier 57 too?

Maine Subscriber

Answer: You’ll need a diagnosis code, procedure code, and possibly a modifier. Here’s how you can arrive at the correct coding for this encounter.

Assigning a diagnosis code in this situation is relatively straightforward, as the ICD-10 index and the code descriptor both use the more common name for the injury. So, you will code the injury as S53.03- (Nursemaid’s elbow). As you know the dislocation is the right elbow, you will add a sixth digit, 1. You will also add the seventh character, A, to indicate the patient is undergoing active treatment (initial encounter).

The procedure itself codes to 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation).

Remember: In this scenario, you’ll use 24640, unless the provider’s notes justify a significant and separate evaluation and management (E/M) service. In this case, you’ll bill for the E/M as well, appending modifier 25 (Significant, separately identifiable evaluation and management service by the same provider on the same day of the procedure or other service) to the appropriate E/M code.

As for modifier 57 (Decision for surgery), there is no need to add this to the claim. Modifier 57 is reserved for E/M services that result in major procedures — procedures that have a global postoperative period of 90 days. The global package for 24640 is only 10 days, which is one indication that it’s a code for a minor procedure.