Pediatric Coding Alert

When primary care pediatricians provide fracture care and laceration repair a common situation when children start playing rough winter sports they can ethically maximize reimbursement by selecting the correct combination of E/M and procedure codes. Coding depends on how the pediatrician handles the fracture. If there is no manipulation, as in the case discussed in this article, there is no surgery and the question is whether to code an additional E/M service. In most cases, you should bill the E/M in addition to the global code.
The Scenario
For example, an 8-year-old falls while ice-skating, and the mother brings the child in without an appointment due to extreme wrist pain and a laceration where the arm scraped on a rough patch of ice. The pediatrician examines the child and takes an x-ray that shows a fracture of the radius. Treatment consists of suturing the laceration, making a temporary fiberglass splint, and referring the child to a supplier to be fitted for a removable Velcro splint.
Fracture Care
The pediatrician stabilizes the fracture. You have a choice of three code sets:

1. CPT 99213 alone established patient office or other outpatient visit

2. 25600 alone closed treatment of distal radial fracture (e.g., Colles or 
 Smith type) or epiphyseal separation, with or without fracture of ulnar styloid;
 without manipulation

3. 25600 with 99213-25 significant, separately identifiable E/M service by the
 same physician on the same day of the procedure or other service. 
 
The choice depends on reimbursement and ethical issues, says Joel F. Bradley Jr., MD, FAAP, a member of the AMA CPT advisory committee, and a pediatrician at Premier Medical Group, Tennessee.
 
When deciding whether to bill an E/M service in addition to the fracture care, ask whether the office visit is "significant and separately identifiable" and whether the documentation shows that it is. If you only treat the wrist fracture, a separate E/M code may not be justified. But that is unlikely in a primary care situation.
 
If the child, in falling, hit his head on the ice as well, and you examine him for possible head injury in addition to treating the wrist fracture, a separate E/M code is justified. If the child complains of shoulder or back pain and you evaluate that complaint and repair the fracture, you can likewise use a separate E/M code. Do not bill an additional E/M code if all you do is treat the wrist fracture and laceration.
 
Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare Pediatrics in Zanesville, Ohio, says not to bill both codes unless you evaluate an additional injury. "I will use an E/M code if I evaluate some other aspect of the injury," Tuck says, adding that this is usually the case in pediatrics. "Generally, [...]