ED Coding and Reimbursement Alert

Emergency department (ED) physicians are often the first line in evaluating, diagnosing and treating orthopedic injuries. And emergency physicians often have an opportunity to provide additional services beyond typical evaluation and management (E/M), so understanding what details to include in the note will be critical for proper reporting --- and recouping pay. 

Avoid Fragmented Fracture Coding

Management of fractures in the ED represents a spectrum of care from supportive care, such as stabilization, ice and analgesia, to emergent manipulation and treatments in between. Treatment of a fracture that is comparable to what would have been provided by an orthopedic surgeon would typically meet the requirement for reporting the service. You can report splint codes as appropriate for supportive care, says Sarah Todt, RN, CPMA, CPC, CEDC, Director, Provider Education & Audit at LogixHealth, a national ED coding and billing company.

When the ED treatment provided is equal to what an orthopedic surgeon would have provided for the same presentation, fracture care codes may be reported. Within CPT®, fracture codes are differentiated as non-manipulative and manipulative. Non-manipulative care is provided when fracture reduction is not clinically indicated and is described in CPT® as “closed treatment without manipulation.” Manipulative fracture care is provided when the physician restores alignment and is described in CPT® as “closed treatment with manipulation.” 

CPT® further defines some fracture care codes as: “open reduction” and “with anesthesia.” Both of these fracture care categories are generally reserved for surgical procedures performed in the operating room and are not usually reported by emergency medicine physicians. Keep in mind, open reduction is a description of the procedure not the injury, so double check the chart documentation to verify you are choosing the most accurate fracture code for care in the ED setting, says Todt.

Isolate “Definitive Care” for Fractures

You can report the fracture care codes described as “without manipulation” when the treatment is considered “definitive.” This treatment goes beyond the supportive care of stabilization of a fracture as a bridge to final orthopedic treatment. Generally, these types of fractures heal without surgical intervention and the care is equivalent to that of an orthopedic surgeon. Definitive care is typically associated with fractures of the nose, ribs, fingers, toes, and possibly clavicle. 

For example: Your ED physician may treat an uncomplicated fracture of a rib with pain medication, detailed discussions on healing and prognosis, and instructions on incentive spirometer use. You would report this service with 21800 (Closed treatment of rib fracture, uncomplicated, each), which has a 90-day global period. The addition of modifier 54 (Surgical care only) is required if the ED physician is not going to be providing all of the follow up care. 

Nasal fractures may also be treated with supportive care. The physician may treat a non-displaced closed fracture of the nose with prescriptions including pain medication and decongestants and are frequently reported with 21310 (Closed treatment of nasal bone fracture without manipulation). This code has a “0” day global period and does not require a modifier, Todt explains.

Other definitive care may be provided for fractures treated with immobilization. 

Coding example: Your physician treats a non-displaced fracture of a proximal phalanx with splinting. You would report 26720-54 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each; Surgical care only.)  Splint codes are considered bundled with fracture care and should not be reported separately, Todt adds.

Take the Guesswork Out of Restorative Care

Restorative care is captured with the CPT® codes described as “with manipulation.” Manipulation is defined as moving the bones to restore anatomic alignment and is often documented as a “reduction.” ED physicians may perform reductions on displaced fractures. 

For example, the ED physician treats a patient with a mildly displaced Colles’ fracture. The ED physician performs a reduction, restoring normal anatomic alignment, and places the patient in a splint. At discharge, the patient is instructed to follow up in several days up with orthopedic surgery. This fracture reduction is reported with 25605-54 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation; surgical care only).

ED physicians may also perform emergent restorative care when a fracture is displaced and is causing neurologic and/or vascular compromise. Often, the urgency of these injuries does not allow time for orthopedic surgery consultation, says Todt. For instance, a patient may present with a displaced bimalleolar fracture. Examination of the affected foot reveals decreased sensation, pulse and temperature. The physician performs a reduction to restore the neurovascular status and applies a splint. You would report his procedure with CPT® code 27810-54 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation); Surgical care only). Following the emergent reduction, orthopedic surgery is generally consulted to assume care, Todt adds.

Bottom line: Orthopedic injuries can often be confusing, so be sure to review the documentation to ensure the anatomical location and the type of treatment. Accurate identification of anatomic location and the type of procedure will allow for proper coding of the service provided, warns Todt.