ED Coding and Reimbursement Alert

Some ED fractures require manipulation; others don’t.

Two common fracture presentations in the ED are distal radius and ankle. When a patient reports to the ED with one of these fractures, the ED physician is almost certain to be the first doctor to see them.

When this occurs, the ED physician will either treat the patient’s fracture or send them to the OR for more involved treatment. If the physician treats the patient’s fracture, you need to be ready to identify the type of treatment and code the fracture care.

Read on for this primer on coding distal radius and ankle fracture treatment in the ED.

EDs Primarily Deal With Closed Treatment, Manipulation

Fracture patients that your ED physician treats will almost certainly call for closed treatment. Closed treatment occurs when the physician uses techniques to treat the fracture without surgically exposing the fracture site. Closed treatment might involve non-invasive or minimally invasive techniques, but the physician makes no incision.

‘Open’ question in the ED: There are also codes for open treatment of the fracture, in which the ED physician does surgically expose the fracture site. While there is always a chance that an ED physician may perform open treatment of a fracture, most will send the patient on to the OR for those surgeries.

When the ED physician performs closed fracture treatment, they might use manipulation. You’ll need to note this, as your code choice depends on it. Manipulation, also called closed reduction, occurs when your physician manually realigns a fractured bone without making an incision. Employing this technique can correctly set the fractured bone(s).

Fall on Wrist Could Lead to Distal Radius Fracture

“Distal radius fracture is one of the most common types of bone fractures. They occur at the end of the radius bone near the wrist,” explained Karen F. Perry, CPC, CPB, CPC-I, OCS, during her HEALTHCON 2024 presentation. “Depending on the angle of the break, distal radius fractures can be classified into two types: Colles’ or Smith.”

The difference: A Colles’ fracture involves a broken fragment of the radius tilted upward. “A Smith fracture is a distal radius fracture with volar displacement or angulation. This often results from a fall on the dorsum of the hand with a flexed wrist,” said Perry.

When your ED physician performs closed treatment of a Colles’/Smith fracture, choose from the following codes:

• 25600 (Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation)
• 25605 (… with manipulation)

Example: A patient presents to the ED after tripping and falling into a table onto their outstretched right hand. The patient reports pain in their wrist, and the physician notes marked swelling. The physician applies a temporary splint and orders X-rays. Wrist X-rays confirm a Colles’ fracture, which the physician sets back into place. They then direct the patient to an orthopedist for follow-up care:

For this encounter, you would report:

• 25605 for the fracture treatment
• Modifier RT (Right side) appended to 25605 to indicate laterality
• Modifier 54 (Surgical care only) appended to 25605 to show that you are only coding for the ED physician’s surgical services
• The appropriate-level ED evaluation and management (E/M) code (99281-99285) for the E/M service
• Modifier 57 (Decision for surgery) appended to the ED E/M code to show that the ED E/M service was separate and led to the fracture care surgery
• S52.531A (Colles’ fracture of right radius, initial encounter for closed fracture) appended to 25605 and the ED E/M to represent the patient’s injury
• W01.190A (Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, initial encounter) appended to 25605 and the ED E/M to represent the cause of the patient’s injury

Ankle Fractures a Possibility

Another common ED presentation is ankle fractures, which can “be a simple break in one bone on which you can still walk, or several fractures which may require surgery,” said Perry.

There are several types of ankle fractures, and it behooves you to know the details on all of them. If you don’t, you’ll have trouble choosing a surgical code.

Check out this quick list of ankle fracture types you’ll commonly see in the ED:

• Bimalleolar fractures “involve both lateral and medial malleoli at the distal ends of the fibula and tibia,” explained Perry.
• Posterior fractures are a break on the lower back side of the shin bone.
• Lateral fractures are at the lower end of the fibula.

With this knowledge of different ankle fractures, it should be easier to navigate the ankle fracture surgery codes you’ll see in the ED. Here’s the ankle fracture surgery codes most likely to be used in the ED:

• 27760 (Closed treatment of medial malleolus fracture; without manipulation)
• 27762 (… with manipulation, with or without skin or skeletal traction)
• 27767 (Closed treatment of posterior malleolus fracture; without manipulation)
• 27768 (… with manipulation)
• 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation)
• 27810 (… with manipulation)
• 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation)
• 27788 (… with manipulation)

Example: A patient presents to the ED after falling off a ladder and landing awkwardly on their left ankle. They reportedly experienced immediate pain and swelling. The ED physician applies a temporary splint, and orders pain medication and X-rays. The X-rays confirm a bimalleolar fracture, which the physician is able to treat using manipulation and application of a cast. The ED physician then directs the patient to follow up with an orthopedist, instructs the patient to avoid weight-bearing on the affected limb, and gives them crutches.

In this instance, the ED physician performed closed bimalleolar ankle fracture treatment without manipulation. On the claim, report:

• 27810 for the ankle manipulation
• Modifier LT (Left side) appended to 27810 to indicate laterality
• Modifier 54 (Surgical care only) appended to 27810 to show that you are only coding for the ED physician’s surgical services
• The appropriate level ED evaluation and management (E/M) code (99281-99285) for the E/M service
• Modifier 57 (Decision for surgery) appended to 27810 to show that the ED E/M service was separate and led to the fracture care surgery
• S82.845A (Nondisplaced bimalleolar fracture of left lower leg, initial encounter for closed fracture) appended to 27810 and the ED E/M to represent the patient’s injury
• W11.XXXA (Fall on and from ladder, initial encounter) appended to 27810 and the ED E/M to represent the cause of the patient’s injury.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC