ED Coding and Reimbursement Alert

Question: A patient presented with an eye injury from a softball. CT results showed medial orbit wall fracture. According to the documentation, the ED physician prescribed Amoxicillin for 10 days, and ice to keep swelling down. The physician referred the patient to an eye specialist for follow-up. Can 21400 be used in addition to an E/M code? If not, when is 21400 appropriate?

Sandy Colson
St. Joseph Healthcare, Albuquerque, N.M.

Answer: If all the physician did was examine the eye, prescribe the medication and refer the patient (there is no mention of treatment of the orbit wall fracture), code the appropriate E/M level with an applicable diagnosis code (i.e., 802.8, fracture, other facial bones, closed, alveolus, palate, orbit).

There are other questions to consider, however. For example, did the ED physician talk to the ophthalmologist doing the follow-up? If the ophthalmologist started conservative management only, and this treatment plan/intention is recorded in the chart, restorative/definitive care may have been rendered and 21400 (closed treatment of fracture of orbit, except blowout; without manipulation) with modifier -54 (surgical care only) would be a consideration.

Note: Without documentation of a known conservative treatment plan, do not presume the ED care was definitive.

Code 21400 was included in the recent 7.1 Correct Coding Initiative (CCI) edits. The codes dealing with an orbital blowout (21385-21395) are comprehensive, with component codes for exploration, excision and decompression of the orbit (67400-67450). Therefore, these codes would be bundled together and are not separately billable. These procedures would not likely take place together in the ED, however.