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, [...]