Question: A 14-year-old patient visited our clinic with an injured second toe of the right foot he suffered during a skiing accident. The physician diagnosed a closed phalangeal fracture, which he reset using manipulation and placed in a plaster cast. He informed the parent to follow up with the clinic for continuing care. Notes indicate a level-three pre-procedure E/M service. How should I code this encounter? What modifier should I append to the E/M code?
California Subscriber
Answer: Many private payers (and Medicare) want you to append modifier 57 (Decision for surgery) to the E/M service code each time the physician provides definitive fracture care and an E/M during the same encounter. For these payers, report the following:
Coding tip: You should M84.374A and not M84.477 (Pathological fracture, right toe[s]) since there is no disease process.
However: Some payers will prefer that you 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 the E/M code when billed in conjunction with certain fracture care codes.