ED Coding and Reimbursement Alert

When your ED physician performs fracture care for a patient, be ready to pounce on evidence of manipulation, as CPT often breaks fracture care codes along the manipulation line.

The $kinny: Let's say the physician performs closed treatment on a fractured collarbone; if she uses manipulation, the service is worth about $106 more than a nonmanipulation encounter.

Use this FAQ to successfully manipulate both types of fracture care codes -- and ethically add to the practice's bottom line.

For coding purposes, "manipulation involves reduction or attempted reduction of the fracture or dislocation," explains Gerri Walk, RHIA, CCS-P, senior manager for Baltimore's Health Record Services Corporation.

There is "open" manipulation, but your ED physicians will almost always perform "closed" manipulation, which occurs when "the physician is repositioning or relocating a displaced closed fracture back to the correct anatomical position without surgically opening it," says Nicole Benjamin, CPC, CEDC, coding education specialist for the American Academy of Professional Coders (AAPC).

When the ED physician provides manipulation, make sure he remembers to document it, "since an orthopedic doctor can be called to treat these fractures as well," Benjamin recommends. If you don't ID manipulation, you could end up costing your ED deserved cash on certain fracture fixes.

Payout: Let's look at CPT codes for closed treatment of a fractured collarbone: 23500 (Closed treatment of clavicular fracture; without manipulation) and 23505 (... with manipulation). Code 23500 pays about $184 (5.09 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666); while 23505, with 8.05 RVUs, pays about $290.

Unfortunately, the word "manipulation" does not make its way into physician encounter notes very often, reports Denise Katz, coder for Dr. David Silverberg in Las Vegas. "Generally, the term 'closed reduction' is used for non-operative treatment of fractures that are treated without surgery," she explains.

Look for: Other key terms that might lead you to a decision on manipulation include "reduce," "align," and "reset," Katz says.

Consider this pair of examples; one contains evidence of manipulation, while the other does not:

Example 1: A 22-year-old male patient reports to the ED with an injured right index finger; the injury happened when an opponent in a football game tackled him. The ED physician documents a level-three E/M, which includes a finger X-ray and administration of pain medication. After reviewing the X-ray the ED physician diagnoses a displaced fracture of the distal phalange. The physician notes that he "reduced finger at distal end, reset fingertip."

He then places the finger in a splint and refers patient to an orthopedist for follow-up care.

This is an example of manipulative care. On the claim, Benjamin recommends that you report the following:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

• modifier 57 (Decision for surgery) appended to show that the E/M led to the fracture treatment

• 26755 (Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each)

• modifier 54 (Surgical care only) appended to 26755 to show that you are not providing any follow-up care

• 816.02 (Fracture of one or more phalanges of hand; closed; distal phalanx or phalanges) appended to 99283 and 26755 to represent the fracture

• E886.0 (Fall on same level from collision, pushing, or shoving, by or with other person; in sports) appended to 99283 and 26755 to represent the cause of the injury. (Note: Beginning Oct. 1, use E007.0 [Activities involving American tackle football] instead of E886.0.)

Example 2: A 16-year-old male patient reports to the ED with an injured left index finger, which happened during a tackle football game. The ED physician documents a level-two E/M with an X-ray and pain meds. After reviewing the X-ray the ED physician diagnoses a proximal phalanx fracture on the hand, which he splints. The encounter notes read "non-displaced fracture splinted in good position. Treatment with NSAIDS for pain." He refers the patient to an orthopedist for follow-up care in 10-14 days.

This is an example of non-manipulative care. On the claim, report the following:

• 99282-57 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the E/M

• 26750-54 (... without manipulation, each) for the fracture care

• 816.01 (... middle or proximal phalanx or phalanges) appended to 99282 and 26750 to represent the fracture

• E886.0 appended to 99282 and 26750 to represent the cause of the injury. (Or E007.0 after Oct. 1.)