ED Coding and Reimbursement Alert

Fracture care is one of the most common procedures performed in the ED, yet many EDs barely break even treating these and other types of orthopedic injuries. To avoid denials and unnecessary fee reduction, coders must know whether the physician provided restorative or definitive care, or whether the patient was only stabilized and referred out.

The ED physician typically identifies the injury's type and location. You can locate diagnosis codes for traumatic fractures in ICD-9's injury and poisoning section, where they are classified according to body area. The ICD-9 code's fourth digit signals whether the fracture was open or closed. Compound fractures or fractures that involve foreign bodies are usually open fractures, while greenstick or simple fractures are closed.

Occasionally, the chart fails to define a fracture as either open or closed, in which case you should code it as closed. That's because an emergency physician usually provides closed treatment only, meaning the doctor doesn't surgically open the injury site, even when caring for an open fracture.

When the chart lacks sufficient detail about multiple fractures, combination categories such as 817.x (Multiple fractures of hand bones) can be handy. However, if the chart includes detailed information about each fracture, then you should code each fracture separately using the fifth-digit subclassification, such as 816.02 (Fracture of one or more phalanges of hand; distal phalanx or phalanges).

In cases of multiple fractures, always list the most severe instance as the primary diagnosis. For fracture dislocations at the same anatomic site, report only the fracture code, because fractures are usually also dislocated as the result of the injury. Therefore, the ICD-9 manual lists dislocation as a nonessential modifier or one that is included in the fracture code.

Once you have identified the diagnosis to support medical necessity, the next crucial step to determining reimbursement is to pinpoint the type of treatment rendered. Coders must also establish what kind of care the physician provided was it restorative or definitive care? Or, was the patient simply stabilized in the ED and referred out to an orthopedic surgeon?

The most confusing aspect of fracture billing is who can bill for what" " says Carol Dodd RHIT senior coding consultant for MedQuist Coding and Information Services in Gibbsboro N.J. The problem results from the fact that "fracture care is coded as a complete or bundled procedure that includes both pre- and post-op care."

Because few ED physicians provide definitive fracture care except for closed nondisplaced fractures an ED doctor will usually stabilize the fracture bill for an E/M and the splint and send the patient to an orthopedist for follow-up. The follow-up period could range from several weeks to several months of office visits which may include changes of casts or further treatment. According to Dodd if the emergency physician bills for only the E/M and the splint the orthopedist could bill the unmodified fracture code.

Use procedure codes for casting and strapping (29000-29799) when the application is an initial service performed without any restorative treatment or stabilization or when the service is a replacement procedure used during or after the follow-up care period.

For initial splint applications and replacement procedures "we code an E/M because the patient presented to the ED we took a history did a review and an exam " says Tracie Christian CCSP CPC director of coding at ProCode in Dallas. "Then the splint would be an additional procedure code." For instance a patient presenting with a simple break in the forearm would be splinted and 29125 (Application of short arm splint [forearm to hand]; static) would be used in addition to the proper E/M level. Be sure to append modifier -25 on the E/M service to show that it was a separately identifiable service from the splint application.

Such initial stabilization usually constitutes a temporary measure that allows for definitive or restorative care to be performed by an orthopedist later. Fracture and/or displacement codes have global periods which means they include a medical examination open or closed treatment of the fracture and normal uncomplicated follow-up care. Any subsequent cast application or supplies should be billed independently as should postoperative complications that require additional procedures.

"If the physician is merely splinting the fracture and referring the patient to an orthopedic surgeon then that is restorative stabilization and not definitive/restorative care " Christian says. But "if we can document that the physician is providing restorative care such as manipulating a dislocation into line then we can bill for that."

Consider an example of restorative stabilization: A patient presents with a displaced fracture of the distal radius. The ED physician documents that he has manipulated the fracture back into alignment applied a splint and referred the patient to his or her own primary physician or orthopedist in five to seven days for follow-up. Code the fractured distal radius (813.42) and the CPT fracture care code 25605-54 (Closed treatment of distal radial fracture; with manipulation; modifier -54 indicates Surgical care only).

Another example is a patient who presents with a dislocated shoulder and the ED physician documents that he has reduced the shoulder dislocation using manipulation and weights applied a sling and referred the patient to her primary physician or an orthopedist in five to seven days for follow-up. In this case code the dislocated shoulder 831.00 and the shoulder relocation code as 23650-54 (Closed treatment of shoulder dislocation with manipulation; without anesthesia; modifier -54 indicates Surgical care only).

Definitive or restorative care may also refer to splinting strapping and/or pain management. For example most rib-fracture cases include pain management as the definitive treatment and are rarely strapped or splinted. In contrast long-bone fractures almost always require casting or other definitive treatment by the orthopedist. Definitive care aims to repair rather than simply stabilize the injury.

Example: A patient presents with a rib fracture and the ED physician documents that he provides breathing instructions prescribes pain medication and refers the patient to his primary physician for follow-up. In this case Christian notes that she would code the rib fracture 807.0x and use the CPT fracture care code 21800-54 (Closed treatment of rib fracture uncomplicated each; modifier -54 indicates Surgical care only).

In another example a patient presents with a non-displaced nasal fracture and the ED physician provides the patient with an ice pack prescribes pain medication and refers him to his primary physician for follow-up. The nasal fracture would be coded as 802.0 and the correct CPT fracture care code would be 21310-54 (Closed treatment of nasal bone fracture without manipulation; modifier -54 indicates Surgical care only).

"We rely upon the physician's documentation to indicate his or her application of splints straps wraps and casts " Christian says. "When appropriately documented we can bill for these services. For example: A patient presents to the ED with a sprained ankle and the ER MD documents that he or she applied a splint to the ankle. We would code 845.00 for the ankle sprain and CPT code 29515 [Application of short leg splint (calf to foot)]."

If the patient broke the splint two days later and returned to the ED for a replacement Christian notes that she would code V54.8 (Other orthopedic aftercare change checking or removal of cast or splint) and 29515 with either modifier -76 (Repeat procedure by same physician) or -77 (Repeat procedure by another physician). If difficulty was encountered in reimbursing both claims the payer may request copies of the record to verify the necessity of repeating the application.

"Very few ED physicians do casting " Christian says. "The fracture care in the ED is typically limited to splinting strapping the use of buddy tape and/or pain management."

Fracture care codes include the application and removal of the first cast or traction device but subsequent replacement of a cast or traction device may require additional codes from CPT's casting and strapping section. "Sometimes a patient presents not with a broken bone but with a cast that has been cracked or gotten wet and we can charge for a reapplication in that instance " Christian says. "Typically if the patient was seen somewhere else and got a cast then they present to the ED we could bill for a cast reapplication because the service was supplied by a different physician.

"A worst-case scenario would be that the payer might wonder why we were submitting such a bill two times and they would want to see the medical records that would show it was necessary to reapply the cast " Christian says. "I could see doing an initial splint application in the ED then the patient breaking the splint two days later. Then we would rebill for the service."