Wiki MDM-Fracture

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KoBee

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Hello everyone -

Having some conflict regarding the level of service 99204 w/ CPT 25600 - no manipulation and puts a short arm cast because patient does have a radius fracture. UHC denied the level of service

We coded a 99204, new patient to ortho

problem = moderate - acute complicated injury
data = minimal - xray order
risk = moderate - short arm cast

I am assuming they consider the short arm cast under " low " and not moderate. I can see this is why? open to suggestions
 
KoBee said:
Hello everyone -

Having some conflict regarding the level of service 99204 w/ CPT 25600 - no manipulation and puts a short arm cast because patient does have a radius fracture. UHC denied the level of service

We coded a 99204, new patient to ortho

problem = moderate - acute complicated injury
data = minimal - xray order
risk = moderate - short arm cast

I am assuming they consider the short arm cast under " low " and not moderate. I can see this is why? open to suggestions
Click to expand...

Since you're being paid separately for the cast, I would guess they aren't considering it part of the level for the E/M service.
 
sls314 said:
Since you're being paid separately for the cast, I would guess they aren't considering it part of the level for the E/M service.
Click to expand...
my issue is the level of service, why wouldn't they accept the level of 99204 or just the E/M in general, pt was seen urgent care a couple days before, but no treatment except a sling, referred to ortho.
 
Cast application would not be coded with the closed treatment of the fracture CPT.

I am guessing they are not allowing the E/M at all with the 25600 as 25600 has a 90 day global and is considered "surgery". The 99204/57 would have to have enough separate documentation to warrant billing it along with the 25600. The payment for 25600 has components for preop, intraop and postop work (even though it's closed treatment). Billing for non-manipulative closed treatment also ticks off patients even though the codes exist.

Concepts (be aware some are older dates but the idea is the same while some of the codes may not be).

Here is an example: Patient goes to urgent care or ED on a weekend, X-Rays, told yup you have a DR fracture, splinted. Comes in to ortho doc Monday morning. The ortho says yup, you have a fracture let's cast it and see if it heals w/o ORIF or perc, Casts it. No additional work is done, they maybe review the outside XR, or take another XR (but they are getting paid for that separately), cast & the patient leaves. You're not going to get a separate E/M out of that. You are being given credit for the work in the RVU for the closed treatment.
The info below is more talking about actual surgery but the concept is the same.
  • Pre-service work refers to work provided before the service or procedure (e.g., reviewing records, discussing procedures with peers, preparing for "surgery").
  • Intra-service work refers to work involved in providing the service or performing the procedure. The intra-service period is defined as patient encounter time for an office visit, or the time spent on the patient’s floor for a hospital visit. With surgical procedures, the intra-service time, also called “skin-to-skin” time, is defined as the period between making the first incision and closing the incision.
  • Post-service work includes all related work provided after the service is delivered (e.g., post-op care, patient stabilization, recovery room care, updating documentation).
 
KoBee said:
my issue is the level of service, why wouldn't they accept the level of 99204 or just the E/M in general, pt was seen urgent care a couple days before, but no treatment except a sling, referred to ortho.
Click to expand...

Amy gave a pretty thorough answer and I know she has ortho experience. I will defer to her on whether or not an E/M service should have been billed at all.

But I also wanted to touch upon the more general question you asked about why a service wouldn't count towards an E/M level. If a service is separately reported with another code, it does not count as a data element for leveling an E/M visit. The time doesn't count when leveling by time, the service doesn't count as a data element when leveling by MDM.

From the AMA E/M Guidelines:

"Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM"

Hypothetically speaking, IF there was enough documentation to support a separate E/M, anything that was part of the 25600 could not be counted towards determining your E/M level.
 
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