Revenue Cycle Insider

Question: A new patient visits an orthopedist after falling from a second-story window. The patient reports pain in the left chest and pectoral region. On examination, the orthopedist finds tenderness and mild swelling in the affected area, and the patient rates the pain as 5 out of 10. The orthopedist orders a four-view rib bilateral X-ray series with a posteroanterior (PA) chest view. Imaging shows a left front chest wall contusion and bruised ribs. The physician applies a rib wrap, recommends rest, prescribes nonsteroidal anti-inflammatory drugs (NSAIDs), and discharges the patient. How should I report this encounter? Is the orthopedist’s treatment of the chest and ribs separately reportable?

Alabama Subscriber

Answer: No, the orthopedist’s treatment of the patient’s rib injury is not separately reportable. However, you can consider the services provided, including application of the wrap and patient counseling, when determining the overall level of the evaluation and management (E/M) service.

On the claim, you should report:

• A code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.) code set for the office visit
• 71111 (Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) for the X-rays
• S20.212A (Contusion of left front wall of thorax, initial encounter) appended to the E/M and 71111 to represent the anterior chest wall contusion
• W13.4XXA (Fall from, out of or through window, initial encounter) appended to the E/M and 71111 to represent the cause of the patient’s injuries.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC