Pediatric Coding Alert

Question: A 9-year-old patient reported three weeks ago for pain in her right shoulder after falling during a ballet recital. The pediatrician provided closed treatment of a fractured clavicle without manipulation, which we reported with 23500 (Closed treatment of clavicular fracture; without manipulation). Yesterday, the same patient came into the office with a fever and nausea. The pediatrician performed a level-three E/M service for the patient and recommended treatment with Tylenol and fluids. Can we report this visit, or is it part of the fracture-care global package?

North Carolina Subscriber

Answer: Since the fever and nausea were not related to the clavicle fracture, you can report treatment for the conditions separately. Report code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity) with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period).