ED Coding and Reimbursement Alert

Question: In last month’s issue, you discussed the difference between fracture care and comfort care, and mentioned that the physician can report an E/M code for comfort care. What about if we confirm that fracture care was performed? Can we bill an E/M with that?

Arizona Subscriber

Answer: Yes, barring any payer-specific edits, you can typically report an E/M code (99281-99285) along with a fracture care code. However, keep in mind that you’ll need to append a modifier to the E/M code, and, in most cases, that will be modifier 57 (Decision for surgery) instead of 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 or other service).

Here’s why: Most of the fracture care codes have 90-day global periods associated with them, which means modifier 57 is more appropriate than modifier 25. Modifier 57 should be used for E/M services on the day of, or on the day before, a procedure with a 90-day global period, if the decision to perform the major surgery happens then. And since most encounters in the ED take place on the day of the E/M service, then this modifier applies to those cases.

Always check the specific fracture care service that the provider documents to ensure that it falls into the 90-day global period category; if so, then modifier 57 is your best bet.