Podiatry Coding & Billing Alert

Question: The physician saw the patient in the ED after she fell off the jungle gym at school. The physician performed a level-three E/M service and diagnosed the patient with a sprain and possible fracture of her left second-digit toe. The physician buddy taped the injured toe to the patient's great toe. Which codes should I report for this service? Would we report a fracture care code?

Minnesota Subscriber

Answer: In this case, you can report the evaluation and management (E/M) service and a strapping code. However, since the physician did not give a definite diagnosis of a fracture, you cannot report a fracture care code.

Buddy taping is when the physician tapes the affected toe to the adjacent uninjured toe. Double-check the physician's documentation to make sure the physician provided no other treatment for the patient. Once you've checked the documentation, then you can report 29550 (Strapping; toes) for the buddy taping service.

You can then report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the level-three E/M service the physician documented.

Don't miss: You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99283 to show that the buddy taping and the E/M were separately identifiable services.