ED Coding and Reimbursement Alert

Question: Can a fracture care code (CPT) for fracture of vertebral traumatic fracture be used with the -52 modifier or would an E/M be more appropriate?

Anonymous CA Subscriber


Answer: The selection of the appropriate code for a vertebral fracture would be determined by several key factors:

location and type of injury,
type of treatment required,
amount of care provided and documented by
the treating emergency physician,
plan of referral to specialist for follow-up treatment,
specific payer rules governing surgical package and or specialist billing.

The CPT Assistant, Volume 6, Issue 2, 1996, indicates that to bill for orthopedic treatments, two issues must be considered: (1) whether the service by the emergency physician constituted performance of the restorative care for the injury; and (2) identification of who will assume subsequent care of the patient.

Note: Restorative care is treatment that is aimed at repairing the injury, not just stabilizing the injury until treated at a later time.

Coding for fracture care also requires a familiarity with the surgical package concept. This concept defines non-starred surgical procedures (those surgical procedures that are not marked by an asterisk in CPT) as packages comprised of three component services; preoperative, intraoperative and postoperative. Unless the emergency physician provides a significant portion of the whole surgical package, an E/M code should be used. For example, if the emergency physician provides the pre- and intraoperative (restorative) treatment and refers the patient to a specialist for follow-up care, the -54 modifier would be affixed to the procedure code to identify the service as surgical care only per CPT guidelines. Modifier -52 should not be used.

If the emergency physician examines the injury and refers the patient to the specialist for the restorative carewhether the care is provided by the specialist in the ED or in the specialists officeand the specialist is assuming follow-up care, the emergency physician is not providing a majority of the surgical package service and therefore should report evaluation and management service, instead of the fracture repair code. The E/M level chosen should be supported by the level of service provided to the patient and documented on the medical record.