tci E/M Coding Alert - 2024 Issue Q2

You Be the Coder: Count on Location for Rib Fracture X-Ray Views

Question: After a level 4 office evaluation and management (E/M) service for an established patient, the surgeon orders a four-view bilateral rib X-ray with posteroanterior chest view. They then perform open treatment on two rib fractures on the right side, and a single rib on the left side. How should I code this encounter? Michigan Subscriber Answer:  You’ll need help from the appropriate modifier to properly report the left and right rib fracture surgeries. On the claim, you should report: 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs) for...

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