Pediatric Coding Alert

Question: A 3-year-old child presented to our office with a history of falling off a chair and injuring his right wrist. After performing a physical, the pediatrician orders an x-ray, which shows a buckle fracture of the right wrist. The physician temporarily protects the injury with a forearm splint and refers the established patient to an orthopedic surgeon for restorative treatment. Can I code for the splinting?

Answer: Because the pediatrician provides only the initial splinting without restorative treatment, you can code for the forearm splinting with 29125 (Application of short arm splint [forearm to hand]; static). If the pediatrician instead performed the definitive fracture care including the pre- and postoperative fracture care, the global fracture code (25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) would include the initial cast or splint.

In either situation, the pediatrician can still code for the x-ray (73090, Radiologic examination; forearm, 2 views). Although the splint is also a separately billable service, some plans may consider the forearm splint (A4590, Special casting material [e.g., fiberglass]) durable medical equipment (DME) and not pay the physician unless he has obtained DME certification.

To report an E/M for the evaluation from the fall, the pediatrician would have to have performed and documented a medically necessary significant and separately identifiable E/M service above and beyond the minor evaluation and management already included in 29125. You'd append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the day of the procedure or other service) to the E/M service that you report with 29125.

CPT indicates you can report further significant identifiable services performed at the time of the cast/splint application. A fall from a chair may involve checking for possible head injury and any other wounds, and will probably require an expanded problem focused history and exam, which could support 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...).