Podiatry Coding & Billing Alert

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:

• 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each) for the fracture care.
• Modifier 54 (Surgical care only) appended to code 28515 to show that you are coding the procedure only and not coding for the follow-up care.
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity…) for the E/M service.
• Modifier 57 appended to 99204 to show that the E/M and fracture care were separate services and that the E/M service resulted in the initial decision to perform the procedure
• M84.374A (Stress fracture, right foot, initial encounter for fracture) appended to 28515 and 99204 to represent the patient’s injury; and
• Y93.23 (Activity, snow [alpine] [downhill] skiing, snow boarding, sledding, tobogganing and snow tubing) appended to 28515 and 99204 to document the activity that led to the injury.

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.