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ED Coding and Reimbursement Alert

Train Physicians to Repair Fracture Care Documentation

Published on Thu May 01, 2003

You can't manipulate documentation to get payment for fracture care services. But you can help your physicians help themselves by outlining for them what type of documentation justifies fracture care codes.

Request that when documenting fracture care, physicians follow these guidelines provided by James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa.:

  • Do not simply state, "fracture." Describe the fracture as specifically as possible, indicating the bones involved and the area of the bone involved, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C. Coders shouldn't have to look at the operative report to find out which area of the bone to report, she says.

    Physicians should also describe whether the injury is open or closed, what type it is (spiral, comminuted, greenstick, etc.), the degree of deformity, and distal, neurovascular, cardiovascular status, as well as the functional status of the limb.
  • State exactly what treatment you provided. Describe whether it was open or closed treatment, manipulation or reduction, with or without anesthesia, and with or without casting, splinting or strapping.
  • If you apply splinting or strapping, state whether you could confirm that it achieved appropriate stabilization or immobilization without neurovascular compromise. You must comment on the splinting or strapping to report it separately. But if you're reporting it in addition to fracture care, it's bundled into that care.
  • State whether you successfully reduced a dislocation.
  • State the number of days until the patient receives follow-up care. Explicitly state whether you provided the initial fracture care management, or whether you're expecting an orthopedist to do so.

     

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