Code This Colles’ Fracture Encounter
Question: A new patient was referred to an orthopedic practice with pain and swelling in their right wrist after a fall. The orthopedist ordered posteroanterior (PA) and lateral X-ray views. The findings revealed a Colles’ fracture. After reviewing the images, the orthopedist performed a closed reduction and immobilized the wrist with a short-arm cast. What codes should I report for the encounter? Minnesota Subscriber Answer: Assign 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) to report the evaluation and management (E/M) visit. You’ll use 73100 (Radiologic examination, wrist; 2 views) to report the PA and lateral X-rays of the patient’s wrist. Next, you’ll report codes for the fracture treatment. Use 25600 (Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) to report the orthopedist’s closed reduction of the fracture. Assign 29075 (Application, cast; elbow to finger (short arm)) for the short-arm cast application to immobilize the patient’s wrist during healing. In the ICD-10-CM code book, you’ll use S52.531A (Colles’ fracture of right radius, initial encounter for closed fracture) to report the right radial Colles’ fracture. The 7th character A is appended to indicate that the patient was undergoing active treatment for the injury. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
