ED Coding and Reimbursement Alert

Question: A 4-year-old patient presents to the emergency department (ED) with an obviously displaced right elbow. The physician performs a history and examination, then orders an X-ray, which shows a displaced radial head subluxation (nursemaid’s elbow). Using manipulation, the physician reduces the dislocation on the first attempt and gives the patient instructions for postoperative care, including setting up an appointment with an orthopedist or primary care provider for a follow-up appointment. Encounter notes indicate that the physician performed moderate medical decision making (MDM) during the evaluation and management (E/M) portion of the service. How should I code this encounter?

Revenue Cycle Insider Subscriber

Answer: You’re going to need a modifier for the E/M and a pair of modifiers for the surgical code to get this claim paid. On the claim, report:

• 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) for the elbow reduction
• Modifier 54 (Surgical care only) appended to 24640 to show the ED physician is only providing the surgical services for 24640
• Modifier RT (Right side) appended to 24640 to indicate laterality
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M
• 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) appended to 99284 to show that the ED E/M led the physician to decide to operate
• S53.031A (Nursemaid’s elbow, right elbow, initial encounter) appended to 24640 and 99284 to represent the patient’s injury

Explanation: You need modifier 54 because the ED physician isn’t going to handle the patient’s follow-up care. Modifier 25 is necessary anytime that the ED physician performs an ED E/M that leads to a procedure with a 0- or 10-day (minor) global period.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC