ED Coding and Reimbursement Alert

Expert answers to 3 fracture FAQs seal the deal

Seeing physician documentation with cryptic terms such as "Colles' fracture," "buckle fracture," "Pott's," and  "Torus radius" can lose you proper payment unless you can assign the correct diagnosis codes to these conditions. Take a look at these three frequently asked fracture care questions to check your coding know-how.

Question 1: How should I report ED fracture care for patients with broken ribs or clavicles? Because there isn't any real, definite treatment beyond what we provide in the ED, do I need to append modifier -54 to these treatment codes?

Answer: If you have provided a definitive treatment, you are entitled to bill for that service, even if there is no follow-up, says Caral Edelberg, CPC, CCS-P, president and chief executive officer of Medical Management resources Inc. in Jacksonville, Fla. That stated, there may or may not be follow-up with these patients, depending on the physician's orders and whether the patient chooses to return to the ED.

Essentially, the treatment for rib fractures (733.1) involves only pain treatment, and while clavicle fractures (767.2 or 810) may require a sling, they are often pain-treatment cases as well. Unless your physician intends to perform a recheck and has ordered the patient to return to the ED for it, he is not providing follow-up care, and you should append modifier -54 (Surgical care only).

Usually, the physician's orders will state his recommendation that the patient see an orthopedist or specialists if there are further problems with the injury. "I think using -54 on those is probably the best way to go," Edelberg says. You don't know what happens when patients leave the ED - whether the ED doctor asked them to come back or not - and modifier -54 allows someone else to provide follow-up care and receive proper reimbursement for it, she says.

"It's kind of a catch-22, because what you are saying is that you don't think that there is any follow-up that is necessary, and yet Medicare has set out a piece of the payment for that follow-up," Edelberg says. "Medicare actually tells you what portion of the RVU is assigned as follow-up." Let Physician Choose Fracture Care Code Rules Question 2: A patient presented with a hairline fracture, but the ED physician didn't have to perform manipulation or casting because the fracture was so minor. Should we report fracture care, or should we just report an E/M code and x-ray code?

Answer: "It's up to the physician to bill this as fracture care or a la carte," says Denise Paige, CPC, a coding manager in Long Beach, Calif., and president of the American Academy of Professional Coders' Long Beach chapter. At a minimum, you should expect to see [...]