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Thread: E/M with fracture charge?

  1. #1

    Default E/M with fracture charge?

    AAPC: Back to School
    I was originally told when I started ortho coding (trained by a co-worker) that if a fracture charge is coded for an initial visit, that an E/M cannot be charged. Whether it's with or without a manipulation, is this correct? Or can an E/M be charged with with a 57 modifier along with the fx code? Thanks!

  2. #2


    IF they perform an office visit. CPT, AAOS and CMS all state that an E/M can be reported when it is the initial decision for surgery. Here is the information:

    AAOS Orthopedic Coding Guide 2008 and 2009 states on page 47 and 48:

    "Surgical evaluation/consultation of a patient, regardless of when it occurs, even if it is on the same day as the surgery, is to be considered a separate encounter as long as the decision to perform the procedure as made in that evaluation/consultation....(they go on and talk about the 10% of the global surgical package that is for 'preop' for like planned procedures and then it states) However, if a patient is seen for the first time or an established patient is seen for a new problem and the 'decision for surgery' is made the day of the procedure or the day before the procedure is performed then the surgeon can report both the procedure code and an E/M code, using modifier 57 or 25 modifier (payor specific) on the E&M code. The E/M service must meet the documentation guidelines for the level of service reported.
    This is true whether a surgical procedure is performed in the OR or the patient undergoes a 'closed treatment' with or without manipulation in a non-facility setting (eg. OFFICE or ED)."

    CPT information from an electronic inquiry Feb 2008:
    " Question: Pt presents to office with nondisplaced colles fracture. Provider does an expanded-focus history and examination and determines it needs closed treatment without manipulation and a cast is applied. Can the provider report 99202-57 or 99213-57 along with 25600 since the initial decision was made to provide a global service with 90 days and will be following the patient? Per the Feb 1996, Nov 2004 and Dec 2004 CPT Assistants it appears an E/M can be reported with FRACTURE CARE whether manipulation or nonmanipulation since they are considered 'major' surgery with modifier 57.

    Answer: .... the CPT codes for 'procedures' do include the evaluation services necessary prior to the performance of the procedure (eg, assessing the site/condition of the problem area, explaining the procedure, obtaining informed consent). However, you would be correct in additionally reporting an appropriate level Evaluation and Management Service code when significant and identifiable (ie, meeting the required key components/counseling) E/M services are performed.

    Because the CPT code 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, is located in the ?Surgery? section of CPT, the CPT surgical package definition applies (see Surgery guidelines). This means that the procedure includes the procedure per se and normal, uncomplicated follow up care. In addition, the code reported may have a 90 day global period assignment as well. In this instance, the modifier 57 would most accurately communicate the distinct E/M service performed."

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