ED Coding and Reimbursement Alert

When a patient reports to the ED with a broken toe and the ED physician "buddy tapes" it to another toe for stabilization, reporting a fracture care code vs. a strapping code is an important consideration -- it might make a difference of $95 per encounter.

Look out for payer discrepancies, however, as there is no golden rule for coding this type of toe-taping.

If the physician provides restorative/definitive care for the patient's broken toe, the service could be fracture care. "Buddy taping is often the definitive treatment for this type of injury," explains Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.

In some cases, the following actions can also represent definitive care for broken toes:

• ice

• pain medication prescription

• discharge instructions.

Example: A patient reports to the ED with a closed fracture to the second digit on his left foot. The physician performs manipulation to realign the tip of the toe, and then buddy tapes it to the great toe.

Since the physician was treating a broken toe, and he provided definitive treatment, this is likely a fracture care scenario. On the claim, report the following:

• 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each) for the fracture care

• modifier 54 (Surgical care only) appended to 25815 to show you are not coding for any follow-up care

• 826.0 (Fracture of one or more phalanges of foot; closed) appended to 28515 to represent the patient's injury.

Caveat: This example illustrates a potential 28515 scenario; there is, however, no formal guidance on buddy taping of toes, which means payers' interpretation of the rule may differ.

Some coders report buddy taping of a broken toe as fracture care every time -- provided the physician is caring for a broken toe. "Buddy taping is the usual method for treating a toe fracture, so the fracture treatment code should be assigned. This is regardless of payer," says Gerri Walk RHIA, CCS-P, senior manager for Health Record Services Corporation in Baltimore.

Best bet: If you are unsure of a payer's policy on buddy taping encounters, check to see what it considers definitive care for broken toes. Then the ED should create its own philosophy/policy on what constitutes definitive care for fractures.

Code fracture care each time you can ethically do so.

At 3.49 transitioned facility relative value units (RVUs), 28515 pays approximately $125 per encounter (RVUs multiplied by 2009 Medicare conversion rate of 36.0666).

Remember that not all buddy taping scenarios will result in a fracture care code. If the physician is treating a sprained or contused toe with buddy taping, be careful to avoid reporting a fracture care code. Without a fracture diagnosis, you cannot prove medical necessity for fracture care codes on a buddy taping encounter.

Best bet: Take the safe route and report a strapping code, which pays about $30 (0.82 RVUs times 36.0666).

Consider this example from LaFleur: A patient reports to the ED with a severe contusion to the second digit on her left foot. The physician buddy tapes the digit to the left great toe, which decreases the patient's pain.

In this instance, report 29550 (Strapping; toes) with 924.3 (Contusion of lower limb and of other and unspecified sites; toe) appended for the encounter.

Coders who want to recognize all their physician's services will want to keep an eye out for these services that might precede buddy taping:

E/M opportunity: Before your ED physician decides to buddy tape an injured toe, she will almost certainly perform a separate E/M service to decide on a treatment course. When you find evidence of a separate E/M in the notes, remember to include the appropriate level E/M code (such as 99282, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.

X-ray opportunity: To check for fracture, the ED physician might also order toe x-rays. When this occurs, be sure to include 73660 (Radiologic examination; toes, minimum of 2 views) with modifier 26 (Professional component) appended.

If you miss the mark on an E/M or x-ray, you'll be costing the ED deserved reimbursement. The average payout for 99282 is $40 (1.09 transitioned facility relative value units [RVUs] multiplied by 2009 Medicare conversion rate of 36.0666). X-ray code 73660-26 pays approximately $6.50 (0.18 RVUs times 36.0666). If you fail to ID both on a claim, it could cost your ED around $47.