ED Coding and Reimbursement Alert

Solve these case studies to report casting with confidence

The difference between definitive and restorative care can make a big difference in payment for your physician's services in the ED. Examine these three patient scenarios to see if you can determine when to report each kind of fracture treatment.

Earn Appropriate Payment for Definitive Care

Patient #1: A patient receives an x-ray in the emergency department that indicates she has a nondisplaced and minor impacted fracture of the proximal radial head, which the physician treats with a short arm splint and sling. The physician states, -The patient should continue wearing the splint for the next three to four weeks.- How should you report this service?

Solution: Because the physician provided all the care the patient will receive for this injury, you should report code 24650 (Closed treatment of radial head or neck fracture; without manipulation) says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems, an ED billing company in Stoneham, Mass. Remember to append modifier 54 (Surgical care only) to the fracture care code, because the ED physician is providing the immediate care only (without additional follow-up).

Additionally, you can probably report an evaluation and management code (99281-99285) if the required medical necessity and documentation are present. For this service, you would choose one of the following codes: 

- 99281--Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making

- 99282---an expanded problem-focused history; an expanded problem- focused examination; and medical decision-making of low complexity

- 99283---an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity

- 99284---a detailed history, a detailed examination, and medical decision-making of moderate complexity

- 99285---within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.

Hint: The doctor's instruction that the patient wear the splint for three to four weeks indicates that the patient won't receive any specific restorative treatment, Granovsky says. This documentation justifies your use of 24650.

Because you have provided a definitive treatment, you are entitled to bill for that service, even if there is no follow-up, says Caral Edelberg, CPC, CCS-P, president and chief executive officer of Medical Management Resources Inc. in Jacksonville, Fla.

Distinguish Restorative From Comfort Care

Patient #2: A 66-year-old patient presented to the emergency department with a Colles fracture with significant impaction. The physician's documentation states that she applied a long arm posterior splint. She talked the patient's case over with the orthopedist, who plans further operative treatment in several days.

Solution: Documentation of the discussion between the ED physician and the other physician equips you with crucial information. The second physician's future operative treatment constitutes restorative care--which means that the splint the ED physician provided was purely for the patient's stability and comfort.

Because the ultimate restorative-operative care--not the ED physician's care--warrants fracture treatment codes, you shouldn't use them to describe the current treatment. The fracture treatment codes will apply to the open procedure the orthopedist will provide later. For this case, you can report 29105 (Application of long arm splint [shoulder to hand]) to describe the ED physician's work, Granovsky says.

Recognize Restorative Care

Patient #3: A 22-year-old male presents to the ED after falling off a skateboard. He has an angulated midshaft radius fracture, and the ED physician notes some decreased perfusion of the hand. The physician administers pain medication, performs a hematoma block and reduces the fracture.

Solution: In this situation, the ED physician provided restorative care by performing manipulation of the fracture. For this service, you-ll report 25505 (Closed treatment of radial shaft fracture; with manipulation),  Granovsky says.

Bottom line: The ED physician provided urgently needed restorative care to maintain blood flow to the hand Don't be shy about reporting the urgent restorative care she performed.