Pediatric Coding Alert

Question: A 3-year-old child comes in 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?

Ohio Subscriber

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). 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-25 (Significant, separately identifiable evaluation and management service by the same physician on the day of the procedure or other service) service 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 E/M included in 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 ...).

You would also code for any follow-up visits with the appropriate E/M level. Remember: The global code includes related follow-up care for a designated period of time, such as 90 days for 25600 using the Medicare Physician Fee Schedule. Private payers may follow this global day inclusion or may create their own time frames.