ED Coding and Reimbursement Alert

"Coders may apply orthopedic codes for the treatment of fractures, sprains and other orthopedic injuries only when the ED delivers definitive care, sometimes also called restorative care. Definitive care aims to repair, rather than simply stabilize, the injury. An ED physician performs definitive care by applying the initial cast, handling the follow-up E/M and managing the fracture until it has healed. Along with casting, definitive care may also include splinting, strapping and/or pain management.

Five Options for Fracture Care Coding

Coders have five options when coding fractures in the ED, explains David McKenzie, director of reimbursement for the American College of Emergency Physicians in Irving, Texas.

1. Code fracture care alone. Although uncommon, if a patient presents with a broken fibula (27780-27781, closed treatment of proximal fibula or shaft fracture or 27786-27788, closed treatment of distal fibular fracture [lateral malleolus]) or tibia (27530-27532, closed treatment of tibial fracture, proximal or 27750-27752, closed treatment of tibial shaft fracture [with or without fibular fracture]), and if there is no pulse in the foot and an orthopedist is not immediately available, the ED would treat the injury. This would be billed as fracture care, and because surgery would likely be required modifier -56 (preoperative management only) would be appended.

In another example, a patient might present with a finger dislocation. The ED physician would reduce the injury, apply the splint (29130, application of finger splint; static or 29131, ... dynamic) and initiate pain management.

Note: In this example, follow-up care is not necessary and the ED physician is not required to use modifier -54 (surgical care only).

2. Code fracture care attaching modifier -54. A -54 modifier indicates follow-up care by a physician other than the original treating doctor. Most patients in the ED require follow-up by another physician, says Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician group staffing a 24,000-visit emergency room in Maryland. It could simply be with a primary care physician. But in the eyes of third-party payers, a -54 modifier should always be applied to indicate you only provided the surgical care and will not supply the follow-up.

Orthopedic codes fall under the surgical package codes and therefore include a global period. This means any pre- (-56 modifier) and postoperative (-55 modifier) care occurring within the declared global period is included in the procedure code. Because of the Medicare 90-day global period, we never bill [orthopedic codes] without a -54 modifier, Granovsky says.

For instance, a patient presents to the emergency room with a closed, nondisplaced great toe fracture of the left foot. The ED physician determines the fracture needs, applies buddy tape, reduces the fracture and initiates pain management. In this case, use 28515 (closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each) and, because the ED physician provided the majority of treatment, apply the -54 modifier. Taping, pain management and E/M are bundled into the global surgical package. Any further service provided during the global period is also included in the global fee and cannot be billed separately.

Granovsky has the -54 modifier hardwired into his EDs charge master. To make it work, however, you have to ask which fractures are legitimate for the ED, he says. His coders met with the ED physicians to determine which codes are appropriate for definitive care in the emergency room. Their fracture care list includes nasal bone (21310); clavicle (23500); phalangeal (26720); distal phalangial (26750); metatarsal (28470); great toe, phalanx or phalanges (28490); phalanx other than great toe (28510) and coccygeal (27200).

Appending the -54 modifier is legitimate when most, but not all, of the work is performed in the ED. For instance, a carpal fracture of the hand (25622, closed treatment of carpal scaphoid [navicular] fracture; without manipulation or 25624, ... with manipulation) would include splinting and pain management and would be billed with the -54 modifier. The ED can usually perform most of the work applying the splint, reducing the fracture and managing the pain for minor fractures. Because follow-up would be handled by the orthopedist at a later date, the coder would apply the -54 modifier with the appropriate orthopedic code.

The orthopedist performing the follow-up care should bill the same fracture repair code used by the ED but append a -55 modifier (postoperative management only). Payers generally reimburse the ED physicians 80 percent for modifier -54 and the orthopedist 20 percent for modifier -55.

The orthopedic codes should not be used if an ED physician provides only temporary treatment or initial stabilization until a specialist in the department or an outside office can administer definitive care. By performing only initial stabilization, the emergency physician is not providing a majority of the surgical package and therefore should report an E/M service (99281-99285), not a fracture repair code. The E/M service code depends on the level of service provided and documented in the medical record.

For example, a patient presents with a broken toe, which the ED physician buddy tapes to an adjacent unaffected toe. The simple service of buddy taping does not warrant use of the orthopedic CPT code for a broken toe (28510, closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation), and therefore the coder would use E/M 99281.

Typically, the application of a splint indicates a lack of definitive care, which must be handled later by a specialist. In that case, splinting (29105, 29125, 29126, 29130 and 29131) is not bundled with the orthopedic global package and would be billed as a separate code along with the E/M service (see #5, below).

Tip: A significant procedure or surgery must result for fracture care codes to be used in the ED (i.e., the patients injury was serious enough to require casting, reductions or an operation).

3. Code for E/M service alone. Bill E/M (99281- 99285) only when the emergency physician examines the injury but does not provide a majority of the surgical package service. For example, if the patient presents with a broken arm, the ED physician would order an x-ray (73090, radiologic examination; forearm, two views), possibly splint the arm (29125-29126, application of short arm splint) and refer the patient for follow-up with an orthopedist either in the ED or an outside office. The splinting would qualify as initial stabilization, followed by casting by the orthopedist (29075, application, elbow to finger) as the definitive treatment.

If the ED doctor refers the patient to the orthopedist for restorative care, the E/M code should support the level of service provided and documented on the medical record.

4. Bill splint application along with E/M.

Initial stabilization with splint: If the ED physician provides initial stabilization and applies a splint (29105, application of long arm splint; 29125-29126; 29130-29131, application of finger splint; static or dynamic; 29590, Denis-Browne splint strapping; 29505, application of long leg splint; 29515, application of short leg splint; and 21085, oral surgical splint), its application can be coded and billed separately with the appropriate E/M code (99281-99285). The patient is referred to a specialist following the ED treatment.

Limited stabilization with E/M: If the ED physician applies a cast to a broken arm (29075), the application would be billed separately and a -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure) should be appended to the E/M code (99281-99285) to indicate that the exam led to the orthopedic service. Although orthopedic services fall under the surgery section of CPT that typically requires attaching the -54 modifier, a decision to cast or reduce a fracture does not necessarily mean a decision for surgery.

5. Strapping, casting or splinting as separately billed services. Any casting (29000-29590) by an orthopedist would be considered definitive care especially in the case of the fracture of larger bones. The ED physician reports the application of splints, casts and strapping as a separately reportable service only when an orthopedic code is not used for the care of a fracture or dislocation. ED physicians rarely perform casting, however. Rather, fracture care in the ED generally involves splinting, strapping and/or pain management.

Only the attending ED physician may code for application of a splint. If the physician instructs a nurse or other provider to do this, the service should not be billed. Medicare and other payers have guidelines regarding the reporting of services not performed by the physician. Check individual payer policies to ensure compliance with CPT rules."