ED Coding and Reimbursement Alert

Tip: Modifier 54 is a necessity on most fracture claims 

When a patient reports to the ED for fracture care treatment, coders will need to be on the lookout for more than just broken bones -- they also need to know if the fracture is open or closed, whether the doctor had to manipulate the injury, and the level of evaluation and management service (E/M) the physician provides in addition to the repair.

Without this information, coders run the risk of undercoding their fracture care encounters. Follow these four steps to the proper fracture care code choice:

Step 1: Answer Open/Closed Question

The initial step in coding any fracture care claim is deciding whether the physician treated an open or closed fracture, experts say.

-A coder must understand the difference between open and closed treatment in order to select the proper CPT code,- says Sharon Hathaway, CPC, coder at Danbury Hospital in Danbury, Conn.

ED physicians typically perform closed fracture treatment. Closed treatment means that the fracture site is not surgically opened by the treating physician. Open fracture care takes place when the physician surgically opens the fractured site and internal fixation takes place, or the physician remotely exposes the fractured bone to allow insertion of an intermedullary nail.

Whereas ED physicians deliver important and meaningful closed fracture care, open procedures are typically performed in the operating room due to the need for complex equipment and the risk of infection. 

Warning: Don't assume that a laceration near a fracture site makes the encounter an open fracture repair. 

-Often, a patient will have a laceration and a fracture in the same area. But an open wound does not mean an open fracture; the patient could have a closed fracture and a laceration, which is two different procedures,- Hathaway says.

Step 2: Find Out if Physician Used Manipulation

Once you have decided if the doctor treated an open or closed fracture, you need to decide if he used manipulation to treat the fracture. The ED physician will use manipulation on a displaced fracture, when -the bone is broken and needs to be realigned at the ends,- says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

If the fracture is nondisplaced, then the bones are close to or in anatomic alignment, and manipulation is often unnecessary. According to Thomas, you-ll see more nondisplaced fractures in the ED than displaced ones.

Example: The operative notes indicate a patient has a closed hairline fracture in his left clavicle. These -crack in the bone- breaks do not require manipulation because they are not displaced. On the claim, report 23500 (Closed treatment of clavicular fracture; without manipulation) for the encounter.

But if the notes state that the doctor had to -move,- -distract- or -realign- the clavicle, the physician manipulated the break and you should report 23505 (... with manipulation) for the encounter.

Step 3: Append Modifier 54 in Most Cases

When you-re coding for fracture care your doctor provides in the ED, you-ll almost always need to append modifier 54 (Surgical care only) to the CPT code in order to file a clean claim, Thomas says.

Why? You are not providing definitive care to the patient in the ED. Most of the time, the ED physician will fix the fracture, but another physician will handle the patient's follow-up care. -In the ED, we don't expect to provide global care for the patient. We provide the surgical component of the service. Whoever does follow-up care and cast changes- gets paid for those services, Thomas says.

Suppose a patient presents with a closed fracture to her ulnar shaft. There is no mention of bone realignment in the notes. The ED physician treats and casts the injury, and helps the patient schedule follow-up care visits with an orthopedist.

On the claim, you should report 25530 (Closed treatment of ulnar shaft fracture; without manipulation) for the fracture care with modifier 54 appended. This lets the insurer know that you are only coding for the surgical component of the code, not the definitive care.

Exception: According to CPT, you can report fracture care codes without modifier 54 if the ED physician performs all of these services for the patient:

1. Local infiltration, metacarpal, metatarsal, digital   block or topical anesthesia.

2. Subsequent to the decision for surgery, one related  E/M encounter on the date prior to, or on the date of, the procedure (including history and physical).

3. Immediate postoperative care, including dictating operative notes, talking with family or other physicians.

4. Writing orders.

5. Evaluation of the patient in the postanesthesia recovery area.

6. Typical postoperative follow-up. (As major procedures, the fracture care codes have 90-day global periods, and most EDs refer these patients out for follow- up rather than providing all of the required -postoperative follow-up- care over the 90 days.)

Step 4: Mark Fracture Care E/Ms With Modifier 57

When a patient presents with a fractured bone, the ED physician nearly always performs a separate service, experts say.
 
-The ED is not a primary-care practice -- each patient is a new patient,- Hathaway says. When a patient arrives with a fracture, -the physician needs to know past medical history, allergies, how the fracture happened, any underlying conditions that might affect patient care, and if there were any other systems injured,- she says. That is why an E/M is necessary.

Consider this example, courtesy of Hathaway: A man arrives at the ED by ambulance after the car he was driving crashed into a car parked on the side of the road. He is boarded and collared, and his left hand is splinted. The physician provides level-four E/M service, during which he checks the patient's other systems for signs of injury. He then diagnoses a closed fracture of the proximal phalanx of the long finger.

In this situation, the physician provided a fracture care service and an E/M service. On the claim,

- report 26720 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) for the fracture care.

- report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) for the E/M service.

- append modifier 57 (Decision for surgery) to 99284 to show that it was a separate service from the fracture care.

-  attach 816.00 (Fracture of one or more phalanges of hand; closed; phalanx or phalanges, unspecified) to 26720 to represent the patient's fracture.

- attach E812.0 (Other motor vehicle traffic accident involving collision with motor vehicle; driver of motor vehicle other than motorcycle) to 26720 and 99284 to represent the patient's auto accident.

When patients report to the ED with broken bones, -an E/M service is always going to happen with the fracture care. Just make sure you have documentation to show that there was separately identifiable E/M provided with the fracture care,- Thomas says.