ED Coding and Reimbursement Alert

Question: My ED physician treats a patient with a severely deformed and injured left clavicle. He performs a level-four E/M, during which he orders x-rays that confirm a closed significantly displaced acromial clavicular fracture. The ED physician consults with an orthopedist, and she recommends closed treatment, a sling, and hospital admission for overnight observation.The physician administers a shot of morphine, then performs closed treatment without manipulation and puts the shoulder in a sling. The physician offers overnight hospital admission for monitoring, but the patient refuses. So the physician releases the patient after helping him schedule a follow-up with an orthopedist. Is the consultation with the orthopedist part of the ED E/M service?

Indiana Subscriber

Answer: The ED consultation with the orthopedist adds to the complexity of the visit and is a consideration in valuing the overall medical decision making. On the claim, report the following:

• 23500 (Closed treatment of clavicular fracture; without manipulation) for the fracture treatment

• modifier 54 (Surgical care only) appended to 23500 to indicate the ED physician is not providing follow-up care

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) for the E/M

• 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 99283 to show that the E/M and fracture care were separate

• 810.03 (Fracture of clavicle; closed; acromial end of clavicle) appended to 23500 and 99283 to show that the treatment and the E/M were separate services.

'Comfort' question: This encounter might appear to skirt the line between fracture care and a "comfort visit," which you could code only with an E/M service. When the physician places a fractured clavicle in a sling or brace, however, it is considered a fracture care service rather than just temporary stabilization.