ED Coding and Reimbursement Alert

If you stop coding your fracture care claim with the appropriate CPT codes and necessary modifiers, you-ll likely cost the practice a reportable E/M service.

"It is highly likely that a physician will perform an E/M with fracture care," reports Yvonne Mayer, CPC, senior coding analyst at One Park Fletcher in Indianapolis.

"In the ED setting, [reporting] an E/M service is almost always justified in addition to any fracture care," explains Michael Lemanski MD, ED billing director at Baystate Medical Center in Springfield, Mass. The physician must obtain history, perform a physical exam and order diagnostic testing --to definitively diagnose the fracture and to evaluate for concomitant injury or illness.

Best bet: Check the encounter notes for evidence of a separate E/M (examination, history, medical decision making) on each fracture care claim.

Example: The physician performs fracture care and an E/M, offers Mayer in this detailed clinical scenario:

A patient presents with a painful second digit on her left hand after being hit with a softball during a game at a local park. The physician documents a detailed history and performs a detailed exam. The physician obtains a two-view X-ray, which shows a displaced fracture of the shaft of the middle phalanx.

The patient receives anesthesia via digital block, and the physician manipulates the fractured finger back into place. The physician then obtains another two-view x-ray to assure proper anatomical alignment, places the finger in a splint and instructs the patient to follow up with an orthopedic surgeon. Overall MDM is moderate.

For this scenario, Mayer recommends that you report the following:

- 26725 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each) for the fracture care

- modifier 54 (Surgical care only) appended to 26725 to show that the physician will not provide follow-up care

- 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) for the E/M

- depending on the carrier, append either modifier 57 (Decision for surgery) or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99284 to show that the E/M and fracture care were separate services

- 816.01 (Fracture of one or more phalanges of hand, closed; middle or proximal phalanx or phalanges) appended to 26725 and 99284 to represent the patient's injury

- E917.0 (Striking against or struck accidentally by objects or persons; in sports without subsequent fall) appended to 26725 and 99284 to represent the cause of the patient's injury

- E849.4 (Place for recreation and sport) appended to 26725 and 99284 to represent the physical location that the patient's injury occurred.