ED Coding and Reimbursement Alert

When your ED physician performs fracture care treatment, you-ll need to identify treatment type and scour the notes for evidence of manipulation in order to choose the right code. Also, you need to include the proper modifiers or you risk miscoding your physician's services.

But if you answer these 4 questions when filing fracture care claims, you-ll be able to submit successful claims each time.

The first thing you-ll have to decide when reporting fracture care is whether the ED physician performs open or closed treatment on the injury. There are separate CPT codes for each.

Example: Let's say your physician treats a patient's radial shaft fracture. With this information, you can narrow code selection to three choices: 25500 (Closed treatment of radial shaft fracture; without manipulation), 25505 ( - with manipulation) or 25515 (Open treatment of radial shaft fracture, with or without internal or external fixation).

But you won't be able to settle on a single code without first knowing the type of treatment the physician performs, confirmed Annette Grady, CPC, CPC-H, CPC-P, an independent coding consultant in North Dakota, during her recent Coding Institute teleconference "Crack the Fracture Code Billing Conundrum."

The ED physician performs closed treatment "when the fracture site is not surgically opened (exposed to the external environment and directly visible)," reported Grady, who is also a former national board officer for the American Academy of Professional Coders (AAPC). The physician may or may not use manipulation or traction during closed treatments, she said.

Open treatment occurs when "the fracture is both surgically opened and visible, or the fractured bone is opened remotely from the fracture site in order to insert an intramedullary (IM) nail across the fracture site," Grady explained. The physician may use internal fixation during open treatment.

Remember: In order to code open treatment, the physician must make a surgical opening, which is not common practice for most ED physicians.

For claims involving closed fracture care, check the operative notes for evidence of manipulation. Your code choice depends on it.

Example: Let's say your physician performs closed treatment on a patient's radial shaft fracture. With this information, you can narrow code selection to two choices: 25500 or 25505 (- with manipulation), but you cannot decide on a single code without answering the manipulation question.

Manipulation explanation: When your physician performs manipulation, he must move or adjust the involved bone(s) to improve their position or alignment, explains Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.

So let's say a patient presents to the ED with a metacarpal fracture. Operative notes indicate that the physician had to realign the bones to facilitate proper healing. On the claim, you would report 26605 (Closed treatment of metacarpal fracture, single; with manipulation, each bone)

Documentation clues: When scanning operative notes for fracture care claims, lookout for words like "move," "distract" and "realign." If these terms pop up in the notes, your physician likely performed manipulation during the fracture treatment.

In most cases, you-ll need to append modifier 54 (Surgical care only) to the fracture treatment code to show that you are billing for only the surgical portion of the code, LaFleur says.

"There may be minor fractures, like a distal phalynx of a finger, that don't really require follow-up care. But any [fracture care code] that requires follow-up that the ED provider is not going to furnish, he should use modifier 54," he explains.

Exception: If the ED physician provides typical postop care for the fracture patient, CPT does not require modifier 54 on your fracture care claim. However, keep in mind that clinically most of these fractures require several follow-up visits to monitor the healing process, and it is unlikely that the ED physician will handle the patient's postop care.

For fracture patients, the answer to this question is nearly always "Yes." While there is an E/M built into all of the procedure codes, "it is probably equivalent to what a provider would furnish an established patient with a straightforward problem," LaFleur says.

In the ED, though, you rarely provide such a low level of E/M before treating a patient. "The patients are new, they have undiagnosed problems, and the need for a procedure has yet to be determined when they present," according to LaFleur. For this reason, the physician almost always performs a separate E/M before deciding on treatment options.

Consider this example from LaFleur: A 4-year-old girl reports to the ED with her mother. The child slipped on some steps and injured her right wrist. The mother says the child went back to playing after falling, but she was not using her arm normally and the wrist was swollen. The patient has no other complaints. Notes indicate a level-three E/M service.

The ED physician gives the child some Tylenol and evaluates x-rays, which reveal a nondisplaced torus fracture of the distal radius. The physician places her arm in a short-arm cast, then chats with the child's primary care physician, who says he will see the child for follow-up care in a month.

Coding: The ED physician performed an E/M, and then treated the patient's fracture. On the claim, report the following codes:

- 25600 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) for the fracture care.

- modifier 54 linked to 25600 to show that you are coding for only the surgical care

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and fracture fix were separate services. (Note: Some payers, such as Medicare, prefer modifier 57 [Decision for surgery] appended to the E/M code because these procedures have 90-day global surgical packages.)

- 813.45 (Torus fracture of radius) linked to 25600 and 99283 to prove medical necessity for the services.