Pediatric Coding Alert

Question: A 3-year-old patient was playing on the monkey bars at a local park when he fell and partially dislocated his elbow. He came to see our pediatrician, who gently moved the bone and ligament back into place. Four days later, the patient came back complaining of the same problem, and our pediatrician performed the same procedure. How should we code this encounter?

Pennsylvania Subscriber

Answer: Your patient suffered an injury that is variously known as a pulled elbow or a nursemaid’s elbow, though the more technical medical term for it is a radial head subluxation. Depending on the elbow that was affected, you would code either S53.031- (Nursemaid’s elbow, right elbow) or S53.032- (… left elbow), adding the seventh character “A” to indicate the first visit.

Though you are not required to, per ICD-10 guideline 20.a.1, you should also assign external cause codes for the encounter that describe how and where it occurred. In this scenario, you could add W09.2XXA (Fall on or from jungle gym, initial encounter) and Y92.830 (Public park as the place of occurrence of the external cause), being careful not to sequence the external cause codes as the principal, or first, diagnosis code.

The procedure your pediatrician performed involves supporting the patient’s elbow with one hand while bending the arm upward, then turning the patient’s palm with the elbow bent using the other hand. The procedure is known as a reduction, and you code it with 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation).

In addition to 24640, you will also be able to bill an evaluation and management (E/M) service from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), adding the appropriate modifier to the E/M to indicate it is a separate service.

Modifier alert: Though you might be tempted to use modifier 57 (Decision for surgery) given that 24640 is listed as a surgery code, this would be incorrect. As a surgery code, 24640 is assigned a global period. But the period assigned for this minor procedure is only 10-days; to append modifier 57, the Centers for Medicare and Medicaid (CMS) would have to define the procedure as major, carrying a global period of 90 days. For a minor surgery such as this, the correct modifier to use would be 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).

The second encounter is a little trickier to code, especially for peds coders who may not be familiar with surgery modifiers. This time, you would append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the 24640. Though the modifier is most often used when a provider divides a procedure into stages, it can also be used when the original procedure was not successful, necessitating a similar, more extensive follow-up procedure to treat the original condition.

You would also use the same ICD-10 codes as before. You would not replace the seventh character, “A,” with the character “D,” indicating that this is a subsequent encounter because the radial head subluxation is still in the treatment phase. Consequently, you would retain use of the seventh digit “A” for the diagnosis and, following ICD-10 guideline 20.a.2, you will assign the same seventh character to the external cause codes.