Pediatric Coding Alert

Question: Encounter notes indicate that the physician performed a level-four evaluation and management (E/M) service for a patient before performing a pair of procedures: closed treatment of the phalanges without manipulation on the patient's left great toe and closed treatment with manipulation of the phalanx on the patient's left pinky toe. How should I report this encounter?

Illinois Subscriber

Answer: You'll be able to report three codes for this encounter, with the help of some modifiers. On the claim, you would report

• 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation) for the great toe treatment
• Modifier LT (Left side) appended to 28490 to indicate laterality, if the payer requires it
• Modifier TA (Left foot, great toe) appended to 28490 to specify surgery area, if the payer requires it
• 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each) for the pinky toe treatment
• Modifier LT appended to 28515 to indicate laterality, if the payer requires it
• Modifier T4 (Left foot, fifth digit) appended to 28515 to specify surgery area, if the payer requires it
• Modifier 51 (Multiple procedures) appended to 28515 to show that the pediatrician performed multiple procedures, if the payer requires it
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99203 to show that the pediatrician performed a significant, separately identifiable E/M service before treating the patient's fractures.

Modifier madness: There are a lot of potential modifier combinations for this claim. Some payers will want the LT modifiers, others might prefer TA/T4 to indicate treatment area, and others might just want modifier 51. The payer could also want a different combination involving these three modifiers, or no modifiers at all on the procedure codes. If you have any doubt as to your payer's preference on these modifiers, be sure to contact a rep before filing the claim.

In fact, the payer might only want modifier 57 appended to 99203 and no other modifiers at all on the claim. You need to know what the payer wants, however, before deciding which modifiers to include/leave off the claim.