ED Coding and Reimbursement Alert

Question: We are in the middle of a debate and need some help for both the facility and the professional side. Here is the scenario:

Patient has sustained a Trimalleolar fracture of the left ankle.  He presents to the ED and receives a reduction of the ankle fracture by the ED physician with procedural sedation, which demonstrates correct alignment after a post reduction film.  Patient is referred to a specialist for evaluation right away since the possibility of a trip to the OR is not ruled out.

Can the ED physician bill the fracture care?

Virginia Subscriber

Answer: You should be able to report the reduction of fracture for the professional service. The physician did seem to reduce the fracture, so they can bill the fracture care with manipulation and use a modifier 54 since they are not providing the follow-up care in the global surgical package. Use code 27818 (Closed treatment of trimalleolar ankle fracture; with manipulation).

The professional billing hinges on whether the emergency physician provided the definitive or restorative care. There is some question perhaps about because of the immediate referral to the Orthopedist; however the emergency physician documented clear manipulation. If only stabilization was provided prior to referral consider a splinting code with an E/M instead of the fracture care code.