Pediatric Coding Alert

Question: When can we bill an office visit in addition to a fracture repair?

Ohio Subscriber

Answer: In general, you should not bill an E/M in addition to fracture repair unless there is a separate reason for the office visit -- for example, if a child falls off a bike and dislocates a finger and the only complaint is the finger. In this case, report 26770 (closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia) only, for reducing the finger dislocation. Do not code an E/M service as well.
 
If the finger is dislocated and the child also fell on the handlebar and complains of a painful abdomen, bill for the office visit as well. Link the fracture diagnosis code (834.02, dislocation of finger; closed dislocation; interphalangeal [joint], hand) to 26770, and link the symptom diagnosis code (789.0x, abdominal pain) to the office visit. The fracture repair will not be paid if the diagnosis code linked to it is abdominal pain.
 
In another example, a mother pulls her toddler back from the curb by his wrist, and the childs elbow dislocates (nursemaids elbow). The insurer will pay only for reducing the elbow dislocation (24640, closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). On the other hand, if the child also bangs his ankle against the curb and complains of ankle pain, a fuller examination is required. Report an E/M service with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. A second diagnosis is not necessary to bill the office visit, but be sure the documentation reflects the additional work performed.