ED Coding and Reimbursement Alert

You could land on the wrong fracture care code or double dip on the follow-up aftercare unless you-ve got a grip on these essential treatment coding conventions.

The first thing you-ll need to deduce from fracture care documentation is whether the physician treated an open or closed fracture.

Your ED physician will typically treat closed fractures, explains Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. He may or may not need to perform reduction to treat a closed fracture.

"An open fracture occurs when the bone has punctured through the skin, or there is a significant break in the skin directly over the fracture site -- not just an abrasion or superficial laceration," says Sharon Richardson RN, compliance officer with Emergency Groups- Office in Arcadia, Calif.

"This makes the fracture more complex, because it is usually angulated, and needs reduction," Lemanski explains of open fractures.

Catch this: "Open fracture treatment is rarely done in the ED; these patients are usually taken to the OR, as there is significant risk of infection, and open fracture treatment usually requires some type of fixation device," according to Richardson.

ED scenario: A pedestrian is struck by a motor vehicle while crossing the street; an exam reveals her right ankle is broken and the bones are protruding through the skin. The ED physician will stabilize the patient and ultimately the orthopedist will provide the open fracture care.

You must next find out if the physician used manipulation to arrive at the proper code choice; CPT's fracture care codes specify whether or not the physician per-formed manipulation

Definition: Manipulation of a fracture involves the physician moving or adjusting the injured bone. Physicians perform manipulation "so the fractured bone returns to its natural orientation and configuration," explains Linda Martien CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla.

"Most open fractures require manipulation and usually operative internal fixation by the orthopedist," Lemanski says. The physician should manipulate any displaced fracture to improve the bones- alignment.

Don't miss: Your ED physician, however, will also typically perform manipulation on a closed fracture. For instance, a cyclist veers from the road and crashes to the ground, causing a fall on an outstretched hand (FOOSH) injury. A level-three exam reveals an angular deformity of the right wrist with swelling and ecchymosis. The ED physician diagnoses a fracture of the distal radius on the right wrist, which he manipulates to properly reduce the fracture. The physician places a fiberglass cast on the injury, helps the patient schedule follow-up visits with an orthopedist and diagnoses her with a Colles fracture.

This is an example of closed fracture care with manipulation in the ED setting.

On the claim, you would report the following:

- 25605 (Closed treatment of distal radial fracture; with manipulation) for the fracture care

- modifier 54 (Surgical care only) appended to 25605 to show that you are billing for surgical care only

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of moderate complexity) for the E/M

- depending on the carrier, either modifier 57 (Decision for surgery) or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and fracture care were separate services. (Many insurers, including Medicare, prefer modifier 57 for E/Ms that lead to fracture care, which has a 90-day global period.)

- 813.41 (Colles fracture) appended to 25605 and 99283 to represent the patient's injury

- E816.6 (Motor vehicle traffic accident due to loss of control, without collision on the highway; pedal cyclist) appended to 25605 and 99283 to represent the cause of the patient's injury.

In the previous example, the orthopedist will provide follow-up, making modifier 54 necessary.

"ED physicians typically perform initial fracture care for patients with nasal, finger, wrist, clavicular, rib, ankle or toe fractures," explains Lemanski. Since most ED fracture patients follow up with their primary care physician (PCP) or an orthopedist, nearly all your fracture care claims should include modifier 54.

Exceptions: Some EDs may be in a position where they have to provide follow-up care for fracture patients; in these instances, you won't need modifier 54 on your claims. For example, if you code at a small hospital with limited orthopedic surgeons in the area, the ED physician may provide all the follow-up care for a fracture patient, Richardson says.

Also, on certain non-manipulative fracture care encounters, the ED physician might meet the definition of definitive/restorative care, making modifier 54 unnecessary for the claim.

Example: A patient presents after a fall at home against a table. He complains of pain in the rib cage area, and X-rays reveal two fractured ribs on the right side.

The ED physician diagnoses the fracture, excludes other complications to the underlying lung tissue, provides pain control and counsels the patient regarding possible complications and the anticipated course of healing. The physician also orders an incentive spirometer to protect against atelectasis and pneumonia.

In this example, the ED physician provides definitive/restorative care (all the care the fracture patient will likely need to heal).

On the claim, report the following:

- 21800 (Closed treatment of rib fracture, uncomplicated, each) for the fracture care

- 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

- depending on the carrier, either modifier 57 (Decision for surgery) or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and fracture care were separate services

- 807.02 (Fracture of rib[s], sternum, larynx and trachea, closed; two ribs) appended to 21800 and 99284 to represent the patient's injury

- E888.1 (Fall resulting in striking against another object) appended to 21800 and 99284 to represent the cause of the patient's injury.