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, [...]