ED Coding and Reimbursement Alert

Know when to report -54, multiple codes

Knowing the requirements for restorative care, the difference between open and closed treatments, and how to bill for multiple fractures is crucial to accurately reporting fracture care in the ED. Follow these tips for flawless reporting when your physician reduces a patient's broken bone.

Double Fractures, Double Codes?

This little piggy has a stress fracture, and this little piggy has a complex fracture. The physician performs a reduction on two metatarsal fractures on the same foot, and then applies a single cast encompassing both fracture sites. Can you bill more than one unit of fracture care?

The answer is a judgment call, coding experts say. To begin with, which codes you can bill depends on whether the physician performed a non-manipulation (28470) or manipulation (28475) reduction.
 
Another consideration: How likely the physician believes each fracture is to develop separate complications during the 90-day global period.

The CPT definitions for both 28470 (Closed treatment of metatarsal fracture; without manipulation, each) and 28475 (... with manipulation, each) specify "each," meaning that you should bill one unit of either code for each fracture. But physicians often will only bill once for multiple closed reductions on the same foot, meaning the decision is up to the doctor.

If you bill the same code more than once, you should use modifier -51 (Multiple procedures) and expect the carrier to reduce the payment for the second code by at least 50 percent, because these codes are not -51 exempt and there is substantial redundancy in treating two fractures so close together. As per routine, unless the emergency department (ED) physician is providing the follow-up care, you would append modifier -54 (Surgical care only) to any fracture services billed.

Consider Itemized Billing for Non-Manipulation

When the physician performs a non-manipulation reduction on two toes and applies one cast, billing for each toe can be "hard to justify," says Margie Vaught, a coding consultant in Ellensburg, Wash. This can add up to a $1,800 bill for a single cast, she says. Instead of reporting multiple units of a code for minor, non-manipulated fractures, you may want to bill for the fracture care only once.

But for a closed reduction with manipulation, you should bill separately for each reduction, Vaught says.

Often each toe will have its own potential complications, says Alameda, Calif., podiatrist Anthony Poggio. One toe could have a non-union fracture, and another could fail to heal in some other way, he says. Also, one toe may require manipulation, but the other one won't. "They're two separate entities, and you should bill for each," he says.

Follow Treatment Type - Not Fracture Type

Make sure you know whether the physician performed an open or closed reduction. According to CPT, you should code fracture care according to the type of treatment the doctor provides - not the type of fracture.

If the physician provided "open" treatment, he made a surgical incision that revealed the fracture so he could see it directly. A "closed" treatment, on the other hand, means that he did not open the fracture site surgically. Usually, ED physicians provide closed treatment, regardless of the type of fracture.

Can You Define Restorative Care?

In order to report a surgical fracture or dislocation code, the ED physician needs to have provided at least some "restorative" care, such as reduction of the fracture or dislocation. Keep in mind that fracture and dislocation codes describe "global care" procedures, and that if your physician won't be performing all that work, you need to append modifier -54 to the fracture treatment code.

Hint: Ask yourself whether the ED physician provided the care that any other kind of physician would provide in the same situation, including any and all follow-up visits covered in the global surgical package. If so, you can report the surgical code without modifier -54. If not - and "not" will most often be the case in the ED - you need to append -54.

For example, if you're going to bill a surgical code for fracture treatment without a modifier, make sure the ED doctor performed these services:
 

evaluated the patient thoroughly enough to exclude possible complications;
 

treated the patient's pain;
 

educated the patient about the condition; and
 

provided follow-up care.

The last item - follow-up care - is crucial to deciding whether to append modifier -54 to the surgical code. If the physician isn't providing this care, you'll have to append -54 to indicate that the ED physician only gave the patient initial treatment.

Ask Payer for Splint and Strap Code Guidelines

Suppose that instead of reducing a fracture, the ED physician applies a strap or splint to stabilize the patient's injury. Instead of reporting a surgical code with modifier -54, you will usually describe this service with a strapping/splinting code, such as 29105 (Application of long arm splint [shoulder to hand]), as well as the appropriate evaluation and management code. 

Tip: If the physician did not personally apply the stabilizing device, ask your local payer about its policies regarding direct supervision. Some payers require that the ED physician apply the device to report the strap/splint code, while others' requirements are less stringent.

If the physician applies a strap, splint, or cast as part of a larger plan of restorative care, you should not report the strap/splint code, but use an orthopedic code (with or without -54), such as 24500 (Closed treatment of humeral shaft fracture; without manipulation).