ED Coding and Reimbursement Alert

Heal your reimbursement with these strategies

If you're having trouble picking fracture and dislocation codes, differentiating between open and closed treatments, and deciding on strap and splint codes, refresh your memory -- and your bottom line -- with these foolproof guidelines.

Don't Mix Up Treatment Types
 
Physicians treat fractures in four different ways, says Mary Brown, CPC, coding specialist for Ortho West PC in Omaha, Neb.: closed treatment, closed treatment with manipulation, percutaneous skeletal fixation, and open treatment. An open fracture doesn't always translate into open treatment (and the same is true for closed fractures and treatment), so be careful when deciding how to apply these terms. "Remember that open and closed fracture types -- the diagnosis codes -- have no correlation with the type of treatment," she says.

For open fractures, the physician may perform either open or closed treatment. "Closed treatment specifically means that the physician did not surgically open the fracture site. Open treatment is performed when the surgeon opens the fracture site and exposes it to the external environment, or when he opens it 'remotely' from the fracture site in order to insert a nail across the fractured bone," says Mike Granovsky, MD, CPC, FACEP, chief financial officer at Greater Washington Emergency Physicians in suburban Maryland.

Was Manipulation Involved?

The next element that you need to determine is whether the case involves manipulation. When a fracture is not displaced, it is close to or in anatomic alignment. Consequently, the physician will not have to perform manipulation to treat the break. But, if the fracture is significantly out of place, the doctor may need to "move," "distract," "reposition," "realign" or "apply tension" to manipulate the displaced bone into correct anatomic position. In the case of minimal misalignment, as often occurs with incomplete fractures, the physician may not need to perform any manipulation.

For instance, a child falls off his bicycle and fractures the middle phalanx bone of his index finger. X-rays show a hairline fracture that is relatively in alignment. The physician reduces the bone. Because no manipulation is involved, you should report 26720 (Closed treatment of phalangeal shaft fracture ... finger or thumb; without manipulation, each). In contrast, if the doctor had to reposition the displaced bone, you would instead assign 26725 (... with manipulation, with or without skin or skeletal traction, each).

Or suppose a patient presents in the emergency department with a broken toe (826.0), so the definitive care is buddy taping. Since the physician didn't open the fracture site, you would report closed treatment with 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each).

If your physician's documentation doesn't specify open treatment, you are generally correct to report closed treatment, considering the statement by the American College of Emergency Physicians that "an emergency physician usually provides closed treatment only, even when caring for an open fracture."

Prioritize to Code Multiple Breaks

When the physician treats patients with more than one fracture, you should first check to see whether any of the fractures are open or complicated by debris. If so, you'll need to list that fracture as the primary diagnosis. If no fractures fit that description, you should code the fracture of the longest or largest bone first.

For example, if a patient has fractured both his femur and one of his fingers, you would report the femur break first with a code from the 820 or 821 series, and then the appropriate 816 series code for the finger. If there aren't significant differences between the sizes of the fractured bones or their complications, you should report first whichever fracture required the most work.

Draw the Line for Definitive Care

When an ED physician provides "definitive" or "restorative" care -- the same care a specialist would -- for a patient with a fractured bone, you should report the appropriate fracture code from the 20000-29999 series. Sounds easy enough, but this simple directive can be tricky because there isn't an airtight definition of "definitive" or "restorative."

Count on these two rules to determine when you should report definitive treatment for an ED physician:

1. The patient received follow-up care from a nonspecialist, like a family practitioner or internist. If the only care the patient seeks after the ED treatment is from a general practitioner, this may indicate that the ED physician took care of the specialized fracture/dislocation treatment. 

If you're concerned that you won't know whether, when, or with whom the patient scheduled follow-up care, keep your eyes peeled for this information in the discharge instructions. "Many physician groups include the discharge (DC) instructions with the material given to the coder. These instructions might advise the patient to return to his primary-care physician, or include instructions to 'See Dr. X, whose specialty is ______,' " Granovsky says. "We fill in the type of doc on the DC form."

2. Don't believe the "72-hour" myth. The 72-hour rule is a bit of coding folklore that incorrectly states that if the physician tells the patient to follow up with an orthopedist in three or more days, the ED doctor likely provided definitive care. "Definitive care is determined on a clinical case-by-case basis, and is not dependent on a time period for follow-up," Granovsky says.

If the patient can wait up to five days for further treatment, this may be an additional indication that the ED physician may have provided the definitive care -- but this time frame isn't set in stone by any means, so be sure to check with your physician to make sure his work complements your code choice.

"Since the definition of definitive/restorative care is clinical and may vary by locality, make sure to speak with your physician group to determine when they feel they are delivering the same care as specialists," Granovsky adds.

Depending on whether the physician provides follow-up care, you may need to append modifier -54 (Surgical care only) to the fracture treatment code to indicate he  provided surgical care only. "Billing fracture care constitutes a global fracture package, just like major surgery," Brown says. CPT includes the following six steps in the global surgical package, Brown says:

1. Local infiltration, metacarpal, metatarsal, digital block or topical anesthesia

2. Subsequent to the decision for surgery, one related evaluation and management encounter on the date prior to, or on the date of, the procedure (including history and physical)

3. Immediate postoperative care, including dictating operative notes, talking with family or other physicians

4. Writing orders

5. Evaluation of the patient in the postanesthesia recovery area

6. Typical postoperative follow-up.

Because you're probably not providing the post-op follow-up (number 6), you will generally append modifier -54, Granovsky says.

Based on the CPT definition of the surgical package, an E/M might also appropriately represent the work that the physician performed subsequent to the decision to render fracture care. This work would include thoroughly evaluating the patient, screening for other injuries, and gathering information to help the clinician decide to provide fracture care.

For payers that abide by CPT guidelines, you may be able to append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code if the doctor performed an entirely separately identifiable service, Granovsky says, or modifier -57 (Decision for surgery) if the service involves predominantly the decision for surgery. For Medicare -- because most fracture care codes have a 90-day global period - you should append  -57 when reporting an E/M code in these situations.