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Wiki Billing new pt E/M for f/u fracture care

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cwestman

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Springville, NY
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Pt dx with right foot 5th nondisplaced metatarsal fx CAM boot was placed at urgent care prior
New to ortho f/u level 99202 -25 and 28470- T9
ICD 10- Z76.89
S92.354A
W10.9xxa
Y92.019
Z47.89
I'm very green /new to ortho coding I believe I followed coding guidelines as pt is new to this ortho, initial treatment occurred out of state provided by urgent care Hoping someone will provide insight for denial .
This pt did not have surgical intervention so modifier 55 couldn't be used I'm at a loss
Appreciate very much your time
Claim denied
Payment Posting At Line Item Level
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.​
 
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They don't want to pay the E/M separately from the 28470. Unless the documentation supports the 25 modifier with a 99202 they will bundle it even with a 25.
The only other thing is the urgent care already billed closed treatment at the time of service.
Re: surgical 54/55: the closed fracture care (with or without manipulation) codes are considered "surgery" even though there is no incision. With the exception of a couple codes they have global periods of 90 days so they are considered "procedures". Look at what section they are in in the CPT book. This is a big issue with patient experience and understanding when they get their EOB it will say surgery a lot of times and go to the deductible with a big fee. They don't understand why it's not an E/M. If it is not explained to them up front they are not happy campers later.

Other posts with some relevant info: https://www.aapc.com/discuss/threads/mdm-fracture.190161/?view=date#post-520691

You can also search the forums for "fracture care", "non op fracture care", "closed treatment" and find more info.
 
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