Primary Care Coding Alert

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?

Illinois Subscriber

Answer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management service that diagnosed the fracture and led to the decision to treat it.
• 27810 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation) for the fracture care
• 73600 (Radiologic examination, ankle; 2 views) x 2 for the x-rays (one before the surgery, and one to ensure proper bone placement postsurgery)
• 824.4 (Fracture of ankle; bimalleolar, closed) appended to 99203, 27810, and 73600 to represent the patient's ankle fracture
• E016.X (Activities involving property and land maintenance, building and construction) appended to 99203, 27810, and 73600 to represent the cause of the patient's ankle fracture. The nature of the "yard work" that the patient was doing will determine the appropriate last digit of this code.

Modifier alert: Be sure to check with your payer before filing this claim. First, you will likely need to append modifier 57 (Decision for surgery) to 99203 to indicate that the E/M service resulted in the initial decision to perform the surgery and therefore is appropriately separate from the surgical package. Alternatively, the payer may want you to append modifier 25 to the E/M service. Since 27810 has a 90-day global period, most payers will probably consider it "major" surgery and look for modifier 57 rather than modifier 25, which is more commonly used with E/M services done on the same day as a minor procedure.

Additionally, some insurance companies might want you to place a modifier, such as 76 (Repeat procedure or service by same physician or other qualified health care professional) or 59 (Distinct procedural service), with the second x-ray code.