ED Coding and Reimbursement Alert

Question: Encounter notes indicate that a patient reported to the ED after someone assaulted them with a rolling pin. Upon exam, the ED physician notes bruising and swelling on the left forearm. The physician orders X-rays, which reveal a pathological fracture of the left radius. After reviewing the X-rays, the physician performs closed treatment of the fracture without manipulation. Encounter notes indicate that during the evaluation and management (E/M) portion of the service, the physician performed moderate-level medical decision making (MDM). How should I report this encounter?

Iowa Subscriber

Answer: For this claim, you should report:

• 25500 (Closed treatment of radial shaft fracture; without manipulation) for the fracture care
• Modifier LT (Left side) appended to 25500 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 or other service) appended to 99284 to show that the E/M and fracture care were significant, separately identifiable services
• M84.434A (Pathological fracture, left radius, initial encounter for fracture) appended to 25500 and 99284 to represent the patient’s fracture
• Y00.XXXA (Assault by blunt object, initial encounter) appended to 25500 and 99284 to represent the cause of the patient’s injury.