ED Coding and Reimbursement Alert

Question: The ED physician performs closed treatment on a patient's ulnar shaft fracture. There are two codes for this procedure: 25530 and 25535. How do I choose between the two codes?

Nebraska Subscriber

Answer: You-ll have to check the physician's notes for evidence of manipulation. If the physician performed the definitive treatment without manipulation, you-d report 25530 (Closed treatment of ulnar shaft fracture; without manipulation). But if the physician used manipulation, report 25535 (- with manipulation) instead.

How to tell: You can always ask the physician whether he performed manipulation before choosing a code, but there are often clues within the encounter notes that can lead you to the proper choice.

When the physician performs manipulation, he moves the affected bone(s) to improve position or alignment. Check the claim for words that might imply he performed manipulation (terms like "move," "distract" or "realign" are often big clues). If the notes contain one of these terms, then the physician likely performed manipulation.

Modifier alert: With most ED fracture care patients, you should append modifier 54 (Surgical care only) to the fracture care code to show that you are only billing for the initial treatment, not the follow-up care for the injury.

Most fracture care codes have follow-up care figured into their relative value units (RVUs). If you are reporting one of these codes and the ED physician is not providing follow-up care for the patient, append modifier 54 to the treatment code.