ED Coding and Reimbursement Alert

When your ED physician treats a fracture, there are a few commonalities that most of the claims will share. There are also a few differences in certain fracture care codes that you need to be aware of to avoid a slip-up at filing time.

From diagnosing the fracture to designating after-care to another provider, fracture care in the ED presents some unique challenges for coders. If you’re prepared, however, you’ll be able to perform your coding duties to maximum efficiency with minimal fuss.

Check out this primer on the most common fracture care codes used in the ED.

Look at This List of Common Fracture Codes

Here’s a list of some of the more common fracture care codes used in the ED:

Nasal bone fracture

• 21315 (Closed treatment of nasal bone fracture with manipulation; without stabilization)
• 21320 (… with stabilization)

Clavicular fracture

• 23500 (Closed treatment of clavicular fracture; without manipulation)
• 23505 (… with manipulation)

Humeral fracture

• 23600 (Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation)
• 23605 (… with manipulation, with or without skeletal traction)

Toe fracture

• 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation)
• 28495 (… with manipulation)
• 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each)
• 28515 (… with manipulation, each)

Note These Commonalities in Codes

There are several things that the above-listed codes have in common, says Samuel “Le” Church, MD, MPH, CPC, CRC, FAAFP, core faculty family medicine residency at Northeast Georgia Health System.

You’ll notice that none of the listed fracture care codes involves open treatment. While open treatment fracture care in the ED

is possible, it’s exceedingly rare. Your ED physician will send open fracture treatment patients to the operating room (OR) in nearly every instance.

You’ll also see that the fracture care codes are subdivided into “manipulation” or “without manipulation,” notes Church. Fracture manipulation (or fracture reduction) is a procedure that’s used to align broken bones to promote proper healing. The ED physician uses their hands or specific tools to adjust the pieces of the fracture into their normal position.

Note: Fractures that require manipulation are those that are angulated, displaced, or dislocated.

There is also the matter of modifiers. All ED evaluation and management (E/M) services that are significant and separately identifiable from fracture care will need to be accompanied by a modifier for payment: Report modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when coding an E/M with a fracture care code with a minor (0- or 10-day) global period, and modifier 57 (Decision for surgery) when coding for an E/M with a fracture care with a major (90-day) global period.

Codes that have a 90-day global period will also require another modifier: 54 (Surgical care only), which shows that you are not coding for the portion of the code that covers aftercare, as the ED physician will hand that responsibility off to another provider.

Remember ED E/M on Fracture Claims

While the modifier you append to the ED E/M might vary depending on the fracture care code, your ED physician will almost certainly perform some type of E/M before caring for the fracture. The physician will have to perform a history and physical exam in order to assess the patient’s injuries and the best course of treatment.

“The E/M associated with evaluating a patient with a fracture is not included in global fracture care. Append modifier 25/57 to the E/M CPT^® code if the treatment of the fracture is performed on the same day or the day following the E/M service,” explains Church. When you are coding for this ED E/M, you’ll choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set.

Check Out These Differences Among Fracture Codes

While there are several things that will be the same whenever you code for fracture care in the ED, there are also some things that are different based on the type of fracture your physician treats. For example, nasal bone fracture care can be performed without manipulation. When this occurs, CPT^® instructs you to report the appropriate ED E/M code instead of a procedure code.

Also, the 21315 and 21320 codes are the only ones with a minor global period of 000, meaning modifier 54 won’t be necessary with these codes. Further, the minor global period means that you’ll append modifier 25 instead of 57 on any separate ED E/M code you report.

There’s also the matter of laterality details on fracture care claims. When your provider performs closed treatment on a clavicular or humeral fracture (23500, 23505, 23600, 23605), you need to remember to append modifier LT (Left side) or RT (Right side) to the CPT^® code, depending on encounter specifics.

When the ED physician treats a patient’s toe fracture, the modifiers you use to indicate that location of the injury will change. You’ll use the following modifiers on 28490, 28495, 28510, and 28515 claims, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania:

• TA (Left foot, great toe)
• T1 (Left foot, second digit)
• T2 (Left foot, third digit)
• T3 (Left foot, fourth digit)
• T4 (Left foot, fifth digit)
• T5 (Right foot, great toe)
• T6 (Right foot, second digit)
• T7 (Right foot, third digit)
• T8 (Right foot, fourth digit)
• T9 (Right foot, fifth digit)

“These modifiers are used to prevent erroneous denials when duplicate CPT^®/HCPCS codes are billed to report separate procedures on different anatomical sites or different sides of the body. For example, physician performs a procedure on more than one toe and/or finger at the same operative session,” explains Falbo.

“Also, reporting these modifiers will potentially avoid medical necessity denials in the future since you are indicating that this is a different toe,” she says.

There are other reasons to use these modifiers; they alert the payer as to which digit you are coding for, which can make it easier to process payments. The modifiers will also assist in explaining the patient’s condition and treatment, making possible future treatments as well-informed as possible.