Orthopedic Coding Alert

Question:  An established patient presents with an injury to her left shoulder. She says she was running and slipped, but couldn’t break her fall before hurting her shoulder. The patient reports pain in the left clavicle area and left upper chest area; notes also indicate swelling in the clavicle area, as well as large bruise on shoulder. The patient cannot raise her arm without wincing in pain. She has no fever.

During an examination, the patient is in obvious pain and holding onto her left shoulder. Further investigation reveals that the pain spreads to her entire left clavicle, with swelling apparent over the area of greatest pain. The patient’s range of motion is severely limited due to pain. The physician takes an X-ray, revealing a non-displaced fracture of the sternal end clavicle. To this point, notes indicate a level-three established patient evaluation and management (E/M) service.

After explaining to the patient the need to stabilize the fracture, the physician applies a clavicle splint and instructs the patient to keep the splint on for four weeks, except for when she’s bathing. The physician prescribes pain medication, schedules a follow-up visit, and tells the patient to call the office if the pain increases or the swelling does not diminish.

How should I code this encounter?

Wisconsin Subscriber

Answer: On this claim, you would report:

• 23500 (Closed treatment of clavicular fracture; without manipulation) for the clavicle repair
• Modifier LT (Left side) appended to 23500 to indicate laterality, if the payer requires it
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99213 to show that the E/M was separate from the clavicle repair
• S42.012A (Anterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture) appended to 23500 and 99213 to represent the patient’s injury.