Pediatric Coding Alert

Question: In the February 2006 Pediatric Coding Alert, the "You Be the Coder" discusses modifier use causing an office visit denial for 99213-57 with nursemaid elbow (24640). The scenario involves a mother who "brings her son in for elbow pain ... The pediatrician diagnoses nursemaid elbow and reduces the subluxation."
 
What in this scenario justifies reporting an E/M code? If you do a procedure such as reducing a nursemaid's elbow (24640), you should bill an E/M code only when you perform a significant, separately identifiable service on the same day. And even if you argue that you have to evaluate the injury before performing the procedure (which I would disagree with because it is not "separately identifiable"), how is a level-three code justified rather than a level-two?

Oklahoma Subscriber

Answer: Your concern on the level of E/M service coded is correct. A 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient ... ; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) would have been better for what would constitute a separately identifiable service for evaluating the history and injury, as well as looking for any other possible associated problems.
 
The level of code sited in the answer, 99213-25, was given only because that was the level of care the questioner provided. It would have been appropriate to suggest the more reasonable 99212-25 in the answer.
 
Many pediatricians are uncomfortable charging for this E/M service and will only bill the procedure (24640, Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). But it is correct coding to bill for the E/M problem-oriented work.