“I have a patient who suffered an inversion, ankle injury. This injury resulted in a severe sprain of the lateral ankle ligaments and a fracture of the fifth metatarsal. The initial treatment involved immobilization using a CAM boot. I billed an E/M code and CPT 28470 at the initial visit. Eight weeks later the patient is in clinic, the 5th metatarsal fracture has healed clinically and radiographically. However, the ankle ligaments are clinically symptomatic and the patient is complaining of continued ankle instability. This clinic visit was focused on continued treatment of the lateral ankle ligaments and we are considering an MRI for further evaluation. I know I am still in the global period for CPT 28470, but I am still working on this ankle! Can we bill an E/M for this visit?”
Despite the fact that the patient suffered two distinct injuries, an inversion ankle injury with a severe sprain of the lateral ankle ligaments and a fracture of the 5th metatarsal, the postoperative global period was set by the procedure that was performed and billed for with respect to the 5th metatarsal fracture. The CPT code that was billed is 28470 which is defined as: Closed treatment of metatarsal fracture; without manipulation each. This is classified as a major surgical procedure code with a postoperative global period of 90 days.
So, here we are eight weeks later and eight weeks into the postoperative global period that was set by the treatment of the 5th metatarsal fracture. The metatarsal fracture is healed, but the ankle ligaments are still symptomatic and an MRI of the ankle is being considered. The big question is: Can an E/M service be billed for this encounter which is specifically focused upon the ankle issue? Yes, you can!
In order to bill for the E/M service and be reimbursed for performing the service, the E/M service needs to be appended by the 24 modifier which is defined as the following: UNRELATED E/M SERVICE DURING POST-OP PERIOD – Use this modifier (only on an E/M code) when you perform an Evaluation and Management service during the follow-up period of an unrelated surgical procedure. You are entitled to bill for an E/M service performed during the follow-up period if that service is not related to the original surgical procedure. In this case, add the -24 modifier to the E/M service code. Make sure you reference this service code to the appropriate unrelated diagnosis on the billing claim.
This is my opinion.
Michael G. Warshaw,