Pediatric Coding Alert

Pediatricians should always code 24640* (closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) for treatment of nursemaid elbow. And, because 24640* is a starred procedure, a separate office visit may also be billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached. Although treatment of this condition is quick and fairly simple, coding only an office visit (as many pediatricians do) results in missed reimbursement.

Nursemaid elbow or, more properly, radial head subluxation is common among young children, explains Jeffrey F. Linzer Sr., MD, FAAP, MICP, assistant professor of pediatrics at Emory University and director of emergency medicine at Childrens Healthcare of Atlanta and Hughes Spalding Childrens Hospital, both in Atlanta. The injury occurs when the head of the radius is displaced by the application of traction force (such as when an adult pulls a child by the hand), allowing the orbicular (annular) ligament to become folded over the head of the radius, displacing the ligament slightly from the capitellum (distal humerus). Manipulation allows the ligament to slip back over the radial head and pop back into its normal position, Linzer says. The injury causes no ligament or joint capsule damage, and x-rays are rarely required.

Bill a Separate Office Visit

When billing for treatment of nursemaid elbow, code an office visit in addition to CPT 24640 *, advises Laura Neuchterlein, senior policy analyst with the American Academy of Orthopedic Surgeons. There is more to the visit than the procedure itself, agrees Paula Ziemski, CPC, coding and compliance educator for the University Services Organization of UPMC Health System, a 450-physician hospital system in Pittsburgh. Even if the pediatrician realizes immediately that the elbow must be treated and reduces it right away to bring relief to the child there must first be a history and at least a limited examination of the area, she says.

Charles A. Scott, MD, FAAP, who practices with Medford Pediatric & Adolescent Medicine of Medford, N.J., concurs, noting that the evaluation is separate and necessary to determine whether there is a fracture. You cant start flipping around a broken arm. If payers say the office visit is bundled to the procedure, you have to fight it. Explain that you need to do the evaluation first to determine whether manipulation is appropriate.

Depending on the circumstances, a high-level office visit may be warranted. For example, the child may have displaced his elbow because, while crossing the street, the mother pulled him out of the way of oncoming traffic. In the process, the child tripped over the curb and bumped his head. The pediatrician must conduct a complete neurological examination: A possible head injury raises the level of medical decision-making considerably. The two enhanced elements (examination and medical decision-making) might justify coding the visit 99214-25, along with 24640*.

Avoid 24600

Do not use 24600 (treatment of closed elbow dislocation; without anesthesia) for treatment of nursemaid elbow. A true dislocation is different from a subluxation and, as reflected in the relative value units assigned to each code (8.99 for 24600, 4.18 for 24640*), requires more work and a higher level of medical decision-making. An elbow dislocation is just that, the actual movement of the bone out of the joint, Linzer explains. There may be ligament and joint capsule damage, as well as an associated fracture. The goals of treatment are to restore blood flow, relieve nerve entrapment and reduce the risk of compartment syndrome.

Additionally, there is a high risk of neurovascular damage with elbow dislocation. Unlike radial head subluxation, elbow dislocation usually requires x-rays. Finally, children rarely suffer a dislocated elbow; the injury occurs when the bone becomes stronger than the surrounding ligaments and tendons, Linzer says.

Sedation is almost never required when reducing a radial head subluxation, Linzer says. The manipulation is quick and the child will usually recover full function in a matter of minutes. When reducing an elbow dislocation, however, sedation or analgesia is almost always required.