Advanced Search

Pediatric Coding Alert

You Be the Coder:

Modifier 25 vs. 57--Expect Some Policy Changes

Published on Thu Jan 19, 2006

Question: A mother brings her son in for elbow pain after she yanked him out of the way of a speeding car. The pediatrician diagnoses nursemaid elbow and reduces the subluxation. Aetna denied the office visit using these codes:

• CPT 24640
• 99213-57.

Did I use the modifier correctly?


New Jersey Subscriber


Answer: Although you correctly appended the modifier to the E/M service code, coding experts usually recommend reserving modifier 57 (Decision for surgery) for E/M services that occur prior to the decision for a major procedure--a code that has a 90-day global period. The National Physician Fee Schedule denotes 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) as a minor procedure, meaning one that has 10 global days. Therefore, you should attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), not modifier 57, to the office visit code (99213, Office or other outpatient visit for the evaluation and management of a patient ...). This coding advice is consistent with Medicare guidelines that private payers may adopt.

The pediatrician's documentation should support the E/M service as significant and separately identifiable from the same-day elbow reduction treatment. Link both 99213-25 and 24640 to ICD-9 code 832.01 (Dislocation of elbow; closed dislocation, anterior dislocation of elbow).

Better way: Use modifier 57 when a pediatrician performs an E/M service that results in the decision to perform a same-day 90-day global period procedure. For instance, a patient presents with neck pain. The pediatrician performs a history, examination and medical decision-making; diagnoses the child with a fractured clavicle; and decides to treat the closed fracture. In this case, because the E/M service involves a decision for a procedure that contains 90 global days, you should assign 9921x-57 and 23500 (Closed treatment of clavicular fracture; without manipulation) with 810.0x (Fracture of clavicle; closed).

But Aetna would deny the modifier 57 appended service even for the above correctly coded claim. The insurer rejected the modifier.

Good news: As of February 2006, the payer will change its policy and allow payment for modifier 57 E/M services. Act fast and appeal any timely submitted claims that were denied for this within the previous 180 days.

The same terms apply to claims for modifier 25 appended 99201-99215 services with 99381-99397 (Preventive medicine services). Aetna also reversed its policy that disallowed separate payment for a problem-focused E/M using modifier 25 on the same day as a preventive medicine service.

Other Articles in this issue of

Pediatric Coding Alert

View All