Orthopedic Coding Alert

Question: A patient comes into the office with wrist pain and the physician determines he has a fracture of the distal radius. Can we code an E/M with a diagnosis code of wrist pain and then 25600 (closed fracture of distal radial fracture)?

Kathy K., North Kentucky Orthopedic Associates
Crestview Hills, KY

Answer: It is a typical orthopedic scenario that the patient comes in complaining of pain in one area of the body, but, after examination, the physician finds the fracture located elsewhere. Usually an initial evaluation of the fracture can be billed with the fracture care. But if youre still under the misconception that you cant get paid for an E/M service and a procedure on the same day, youre costing your practice revenue to which it is ethically entitled. As long as you meet the requirements for the level of service with history, exam and medical decision-making, then technically you can bill for it. Of course, you want to check with your major payers for their perspective. For example, in Michigan the Medicare carrier would pay for an office visit and fracture care but Blue Cross would not, while Aetna might. Therefore, append a -57 modifier (decision for surgery) on the correct level of the E/M code. It is not necessary to use a separate diagnosis for the two services. In fact, you dont even have to worry about coding the wrist pain.