ED Coding and Reimbursement Alert

Specialist-caliber broken bone care elevates treatment to procedure status.

A patient reports to the ED with a broken bone. The ED physician treats her and sends her home. This is automatically a fracture care claim & right?

Wrong: Even if the physician confirms a fracture, this does not guarantee you can choose a fracture care code.

Read on to find out when to code for an E/M instead of fracture care, and which modifier to use when your physician provides both services during the same encounter.

Report E/M for Comforting Encounters

One of the top patient problems in the ED is broken bones, confirmed Raemarie Jimenez, CPC, CANPC, CRHC, during her presentation on ED auditing at the recent AAPC national conference in Las Vegas. So coders need to know all they can about fracture care.

When examining a claim, Jimenez recommends that the coder ask herself: Did the physician treat the patients fracture, or did he just make the patient more comfortable?

If he just makes the patient comfortable, then you cannot code fracture care, she explained.

Bottom line: The ED physician must provide the same care as a specialist would in order to report fracture care for a patient.

Example: The ED physician treats a patient with a suspected right leg fracture; she examines the leg, takes a pair of x-rays, and determines that he has a closed tibia fracture. She puts the leg in a splint, and then advises the patient to visit an orthopedist as soon as possible for additional treatment, including casting.

This is an E/M service, not fracture care, Jimenez confirmed. On the claim, youd likely report an E/M such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) for the encounter.

Code Separately for Fracture Care, E/M

So if the ED physician provides mostly comfort measures and the patient is sent to the orthopedist for more definitive care (such as casting), code only for the E/M, confirmed Lisa Jensen, MHBL, CPC, FACMPE, during her presentation on common modifiers at AAPC 2009. If the ED physician definitively treats the patients fracture, however, youd report a fracture care code, said Jensen, physician coding consultant for Reimbursement Management Consultants Inc. in Clackamas, Ore.

Example: The ED physician treats a patient with a suspected right leg fracture; she examines the leg, takes a pair of x-rays, and determines that he has a closed tibia fracture. She resets the bone and places his lower leg in a plaster cast. She then advises the patient to schedule follow-up visits with an orthopedist.

For this encounter, you can report an E/M and a fracture care code. On the claim, report the following:

" 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction) for the fracture care

" The appropriate-level E/M code based on notes

" Modifier 54 appended to 27752 to show that you are not coding for the patients follow-up care

" Depending on the insurer, either modifier 57

(Decision for surgery) or 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M to show that it was a separate service from the fracture care.

Careful: Modifiers Might Vary for ED E/M

Medicare and many commercial payers will want to see modifier 57 each time the physician provides an E/M and fracture care in the same encounter. There are, however, some carriers that prefer modifier 25 to 57 in certain instances.

Some payers follow the rule that modifier 25 would be used if the global days [of the CPT code] were 0-10, and modifier 57 would be used when global days are 90 or greater, explains Yvonne Bouvier, CPC, senior coding analyst with Bill Dunbar and Associates in Indianapolis.

So a fracture care code such as 21310 (Closed treatment of nasal bone fracture without manipulation), which has a 10-day global, might prompt you to append modifier 25 to the E/M instead of 57.