ED Coding and Reimbursement Alert

Question: We saw a patient who presented complaining of a right wrist injury, but we are having trouble assigning the right codes to the service. Following is the note:

History: This 68-year-old woman was standing on the counter trying to change a light bulb when she stepped down and lost her balance, falling on her outstretched right hand. The injury occurred just prior to arrival. Her only complaint is 6 out of 10 pain in the wrist area. She says this was not a syncopal episode. She did not hit her head. She denies chest pain, shortness of breath and palpitations. No injuries elsewhere other than in the right wrist area. She has not taken any medication for the pain. She has had no recent illness, cough cold or congestion.

Past Medical History: No chronic significant medical problems

Medications: Her only medications are Flonase and Ambien as needed.

Allergies: She has no allergies, although she says she is sensitive to pain medications and narcotics sometimes cause nausea.

Social History: She is right-handed. She is here with her husband. They are retired. I reviewed her medical record. She has had no recent activity, only one remote outpatient procedure.

Physical Exam: at 0030

Vital Signs: Blood pressure 121/55 with a pulse of 80.

General: Thin, well-nourished woman is sitting on the side of the bed, holding her right forearm. She is a bit anxious.

Abdomen: Soft, non-tender, no masses

Cardiac: Regular rhythm and rate with no murmur or gallops

Respiratory: Lungs clear, no rales or wheezes

Extremities: Examination of the extremity shows an obvious Colles type deformity of the right wrist with mild tissue swelling but no significant bruising. The distal extremity is neurologically and vascularly intact. The forearm, elbow and above are non-tender with normal range of motion.

X-ray shows a right Colles fracture with dorsal angulation of the distal fracture fragment. The ulnar styloid is intact.

ED course: The patient was given a Percocet. I discussed the options included splinting and following up with an orthopedist versus reduction in the emergency department. She says she would prefer reduction here in the ED rather than a temporary splint and waiting to see ortho.

Procedure: Colles fracture reduction. I initially placed 2% lidocaine plus epinephrine buffered with 8.4% sodium bicarbonate into the right radius fracture site and then placed the patient in finger traps and used traction with IV bags, this improved the alignment. I then gently manipulated the fracture to what I felt was an acceptable anatomic position. I placed the patient into a well-padded sugar tong splint and repeated the x-ray, which showed restoration of correct anatomical position with good reduction. On recheck, the patient is neuro and vascularly intact. Aftercare was discussed. I am giving her a prescription for Percocet and Valium 5 mg #10 as an alternative analgesic. Follow up: I’m giving her the name and phone number for several orthopedic doctors for follow up.

Discharge Diagnosis: Right Colles fracture

Procedure: Reduction by closed manipulation of Colles fracture and splinting by physician.

Codify Subscriber

Answer: You cannot report the splint application in addition to the fracture care code 25605 (Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) because casting and splinting are included in that procedure. 

On the claim, you should report:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; detailed examination; medical decision making of moderate complexity ...) for the E/M service based on the detailed H&P and moderate MDM with acute complicated injury and prescription
• Modifier 57 (Decision for surgery) appended to 99284 to show that the E/M and fracture care were separate services. You’ll select modifier 57 for this because the fracture care code has a 90-day global period.
• 25605 for the fracture care
• Modifier 54 (Surgical care only) attached to code 25605 to indicate you are not providing the full global care package including follow-up

The X-ray interpretation is not separately billable based on the chart documentation as it does not meet the requirement of a separately identifiable signed written report for the professional component of the service.