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E&M with closed fracture care?

  1. Question E&M with closed fracture care?
    Medical Coding Books
    I want to know can we bill E/M with any type of closed fracture care? Anthem Healthkeepers is denying as inclusive to closed treatment. Please help me.

  2. #2
    Columbia, MO
    As long as you can support the usage of the 25 modifier you should be able to appeal and win. If the evaluation of the patient includes evaluation of other body areas for other possible injuries, then you have no problem. Remember you do not need 2 dx codes when you use the 25 modifier. Just the evaluation that is over above and beyond what is ordinarily required for the procedure. If the evaluation is only for the fracture then you do not have enough to support the E&M charge. The fracture repair code includes that the physician will evaluate the fracture area.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    South Bend
    I believe that closed fracture care has a 90 day global. For this reason I believe that the 57 modifier would be more correct than the 25.

    I am in Indiana and NGS is our local carrier. In chapter 12 of our Medicare Manuel it states: "The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedure."

    I believe the definition of major surgical procedure is a 90 day global.

    I do not know Anthem's policy. This is an interesting question you have asked. I'm interested in reading other's response as well.

  4. #4
    Columbia, MO
    Ah I always say 25 and I mean 57 on this one thanks for the catch! However I know some that use the 25 and it is accepted but you are correct it should be the 57.

    Debra A. Mitchell, MSPH, CPC-H

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