ED Coding and Reimbursement Alert

Heal your reimbursement with these strategies

Choosing the right fracture or dislocation code can be tricky. Knowing how to differentiate between with manipulation and without manipulation can help you file a clean claim the first time.

Was Manipulation Involved?

CPT^® describes fracture care as being either with manipulation or without manipulation. And you need to be careful when deciding how to apply these terms, says Mike Granovsky, MD, CPC, FACEP, President of LogixHealth, a national ED billing and coding company based in Bedford, MA.

The first step to choosing the best code to describe your fracture care, is determining whether the case involves manipulation. When a fracture is not displaced, it is close to or in anatomic alignment. So, 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(s) 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. CPT^® defines manipulation to specifically mean the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces.

For example: 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. 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), Granovsky explains.

Prioritize to Code Multiple Breaks

When an ED physician provides “definitive” or “restorative care”, or the same care a specialist would provide for a patient with a fractured bone, you should report the appropriate fracture code from the 20000-29999 series of CPT^®. This can confuse coders who have heard different definitions of what constitutes “definitive” or “restorative 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 could be an indication that the ED physician provided the definitive care — but this time frame isn’t set in stone by any means. Be sure to check with your physician to make sure his work and your code choice are in agreement.

Since the definition of definitive or 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.

Don’t forget the 54 modifier

If the emergency physician is not expecting to provide the follow-up care associated with the presenting fracture, you need to append modifier 54 (Surgical care only) to the fracture treatment code to indicate he provided surgical care only. Reporting fracture care constitutes a global fracture package, just like major surgery. CPT^® includes the following six steps in the global surgical package, says Granovsky:

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 post-anesthesia 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 code 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 follow CPT^® guidelines, you may be able to append modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional 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 you may include 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.