Anesthesia Coding Alert

Coding for an anesthesiologist's involvement in bone fracture repair requires knowing whether the procedure is a reduction or repair and the type of treatment closed, open or percutaneous skeletal fixation. However, the patient's chart doesn't always supply that information, so coders must understand key phrases and work closely with the anesthesia provider to supply adequate documentation.

Reductions are the alignment of fractured bone segments in an acceptable manner; once aligned, the fragments must be fixed in place so the bones don't get out of alignment and need to be reduced again. The terms "reduction" and "repair" are sometimes almost used interchangeably, but repairs are not usually associated with fractures, says Sharon Ryan, senior coder with the physician group Anesthesia Associates of Massachusetts in Westwood.
 
CPT 2002 states, "Closed treatment specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized) Open treatment is used when the fracture is surgically opened (exposed to the external environment). In this instance, the fracture (bone ends) is visualized and internal fixation may be used Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (i.e., pins) is placed across the fracture site, usually under x-ray imaging."
 
"Open or closed tells whether or not an incision is made in the skin and muscle over the fracture site," explains Mike Casto, assistant director of Anesthesia Associates in Alexandria, Va. "When a diagnosis is 'open fracture' that means the bone has broken through the skin. For a closed reduction, the physician puts the bone back in place without opening the patient up.
 
"Whether the fracture is open or closed is generally easy to see," Casto continues. "When there is an open fracture, there is an open wound of the skin at the site of the fracture with a portion of the bone protruding. Closed fractures don't break the skin. If an incision is made when gaining access to the fracture site, the procedure would be an open reduction; when pins are placed through the skin the reduction is percutaneous."
 
Ryan adds that when the operative notes specify open or closed with a fracture, the physician is usually referring to a reduction, not a repair.

Types of Reductions

Examples of types of reductions that fall into each category are:

Open reduction: One example of an open reduction is a fracture of the femoral neck in which an incision in the hip region is required to gain access to the upper femur. A plate and screw-type internal fixation device could then be implanted to stabilize the sections of bone.

Closed reduction: This type of repair can be used for fractures that can be manipulated (if needed) into position and don't usually require the insertion of internal fixation devices, such as when a child's broken arm requires strong manipulation (hence, general anesthesia) and a cast (01730, Anesthesia for all closed procedures on humerus and elbow). However, on some occasions a closed reduction can be internally fixated, such as a femoral rodding.

Percutaneous reduction: This type of reduction can be used for open and closed fractures, but does not apply to open or closed reduction. The reduction often involves using x-ray guidance for placement of pins into the bone sections. For example, a fracture of the femoral neck can have pins placed through the skin and into the lateral proximal femur (just below the greater trochanter) through the fracture site and into the femoral head.
 
"There are several codes for each type of these procedures," Casto says, "although repair and reduction can be grouped together. The codes will vary with the bone fractured, what part of that bone was fractured (e.g., shaft, neck, etc.), and how the fix was set (pins, intramedullary implant, etc.)."
 
"All of the surgical codes related to these procedures are in the musculoskeletal system section of CPT, codes 20000-29999," adds Kim Arnett, CPC, coding specialist with the physician group Georgia Anesthesiologists, PC, in Marietta. Locate the specific bone site. Go to the fracture and/or dislocation subsection. Choose the code based on the fracture site and the appropriate description of open, closed or percutaneous skeletal fixation.

Anesthesia or surgical codes may be reported for fracture repair services. Ryan's group uses either code based on the carrier's preference. Casto codes only with surgical codes; Anesthesia Associates' computer system automatically converts to anesthesia codes when the carrier requires it. Arnett usually applies the surgical code first and converts it to the anesthesia code for all carriers (not just those that require anesthesia codes) to ensure that the group bills the correct number of base units for the procedure performed.
 
Arnett shares examples of how surgical and anesthesia codes apply to coding for a closed fracture of the tibial shaft, based on how it was treated. Regardless of treatment, the same diagnosis applies 823.20 (Fracture of tibia and fibula; shaft, closed; tibia alone):
 

Open repair of the tibial shaft with intramedullary implant: Use surgical code 27759 (Open treatment of tibial shaft fracture [with or without fibular fracture] by intramedullary implant, with or without interlocking screws and/or cerclage) or anesthesia code 01480 (Anesthesia for open procedures on bones of lower leg, ankle, and foot; not otherwise specified).

Closed repair of the tibial shaft with manipulation: Use surgical code 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction); the anesthesia code is 01462 (Anesthesia for all closed procedures on lower leg, ankle, and foot).

Percutaneous reduction of a tibial shaft fracture: Use surgical code 27756 (Percutaneous skeletal fixation of tibial shaft fracture [with or without fibular fracture] [e.g., pins or screws]); the anesthesia code is 01462.

Because most anesthesia codes apply to regions rather than smaller areas, the specificity of the surgical definition is lost when you convert it to the appropriate anesthesia code. For example, codes 27175 (Treatment of slipped femoral epiphysis; by traction, without reduction) and 27252 (Closed treatment of hip dislocation, traumatic; requiring anesthesia) are very specific surgical codes that crosswalk to the less-specific anesthesia code 01200 (Anesthesia for all closed procedures involving hip joint).

A detailed operative report (OP) is essential to accurate coding. Casto notes that the OP may read "fracture of the proximal femur," but there are many sites on the proximal femur that may fracture (neck, intertro-chanteric, pertrochanteric, proximal shaft, etc.). With sites that have more than one bone, the fractured bone needs to be identified. A report that states "wrist fracture" does not help a coder because there are eight carpals and seven bones of the hand/arm connecting to these wrist bones. These details may not change the anesthesiologist's level of reimbursement because, e.g., the same reimbursement occurs with any wrist bone that is fractured, but it affects which ICD-9 code is used to report the procedure.
 
Casto says the physician needs to specify the fractured bone, the site on the bone that is fractured, whether it is an open or closed fracture, and features on the bone that may be fractured (styloid process, neck, etc.). Other key information to help code the procedure includes:
 

whether manipulation was involved in the repair
 

the treatment of each bone
 

the type of internal fixation used (pins, plates, screws, etc.).

The physicians whom Casto and Ryan work with usually include enough information on the patient's chart to make coding less difficult. They attribute this to their level of communication with the physicians.
 
"I gave our anesthesiologists and certified registered nurse anesthetists a list of the information I needed to code properly so they know to be as specific as possible for both the procedure and diagnosis," Casto says. "I've met with most of the staff to discuss some of the specifics needed and have a list posted in the hospital for their reference."
 
If the information isn't obvious, ask the physician. If that doesn't work, medical records will indicate more detail on the fracture and the procedure performed. Ryan notes that if you're still unable to get the appropriate code and if the physician does not specify that the procedure is open, it is considered closed. However, because reimbursement is generally less for closed procedures than for open, obtain a copy of the OP to verify what the surgeon did.