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tci ED Coding & Reimbursement Alert - 2022 Issue Q4

You Be the Coder: Shoulder Separation and Repair

Question: The ED physician performs a level-four ED evaluation and management (E/M) service for a patient with right shoulder pain. After a complete shoulder X-ray, the physician diagnoses subluxation of the right shoulder (the hospital owns the X-ray equipment). The physician then performs closed treatment of the separated shoulder. During the surgery, they use manipulation. How should I report this encounter? Pennsylvania Subscriber Answer: On the claim, report: 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the shoulder treatment. Modifier 54 (Surgical care only) appended to 23650 to show that the ED physician won’t be...

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