Primary Care Coding Alert

Question: The FP meets a 27-year-old patient who is 16 weeks pregnant at the local hospital after an accident at her workplace. She fell down the stairs and reports pain in her twisted left ankle. The FP performs a level-three E/M in the hospital outpatient unit, during which she diagnoses and wraps a sprained left internal collateral ligament; then, she performs obstetrical ultrasound (US). After examining the US, the physician determines that the fetus has not sustained any injury. Do I need a modifier for the US?

Georgia Subscriber

Answer: Since you are using the facilitys equipment, youll need a modifier for the US. On the claim, report the following:

" 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) for the US

" modifier 26 (Professional component) appended to the US code to show that you are coding only for the physicians service, not the technical component of the code

" 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity &)

" modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213 to show that the E/M and US were separate services

" 845.01 (Sprains and strains of ankle and foot; ankle; deltoid [ligament], ankle) appended to 99213 and 76805 to represent the patients ankle injury

" V22.2 (Pregnant state, incidental) appended to 99213 and 76805 to provide further specifics on the patients condition

" E880.9 (Fall on or from stairs or steps; other stairs or steps) appended to 99213 and 76805 to show the cause of the patients injury.

Note: Coding would change if the FP treated the patient in the hospital ED; in that case, you would chose an ED E/M code, such as 99282 (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 low complexity), rather than 99213.