Pediatric Coding Alert

Question: An established patient reported to the office after falling off the monkey bars at school. The pediatrician treated the child for multiple abrasions and contusions to his right arm, and splinted the patient's right ring finger, which was fractured. The pediatrician also conducted an exam to rule out any other injury, such as a concussion. How should I report this claim?

Massachusetts Subscriber

Answer: You should report the finger fracture treatment first, using CPT 26720 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) with the diagnosis code 816.00 (Fracture of one or more phalanges of hand; closed; phalanx or phalanges, unspecified). The splint and cast are included in this procedure, so you cannot bill separately for either.
 
Because the pediatrician had to check for a concussion and treat minor abrasions, he likely performed low- to moderate-level medical decision-making. With thorough supporting evidence, you would report the E/M service with 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity). Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 with the diagnosis codes 923.8 (Contusion of upper limb; multiple sites) and V71.4 (Observation following other accident).
 
- Information for Reader Question and You Be the Expert provided by Richard H. Tuck, MD, FAAP, medical director of Quality Care Partners in Zanesville, Ohio.