ED Coding and Reimbursement Alert

Some coders confuse the indication of an open or closed fracture to mean that the treatment of that injury was open or closed, when, in fact, these terms mean two different things.

An open fracture is one where the skin overlying the fracture has been violated through the subcutaneous tissue, explains John Stimler, DO, FACEP, a practicing emergency physician in Jacksonville, FL, and a past president of the Florida chapter of the American College of Emergency Physicians. Often, this is because one end of a fractured bone has punctured the skin. However, a laceration or puncture wound over the fracture would also constitute an open fracture, he adds.

A closed fracture is one in which the skin overlying the broken bone is not violated through the subcutaneous tissue.

A superficial contusion or abrasion that is not into the subcutaneous area would be considered a closed fracture, Stimler notes. Open treatment of a fracture indicates that the physician had to surgically open the skin and go in to repair the injury, says Kenneth DeHart, MD, FACEP, president of Care First Health Specialists, an emergency physician group in Myrtle Beach, SC, and chairman of the American College of Emergency Physicians advisory committee on coding and nomenclature.

A good example would be a bone that is fractured in several places, he explains. The physician would have to make an incision and go in and set each of the pieces. Injuries that are this complicated are almost always managed by a consulting physician and not by the ED doctor, notes DeHart.

To be clear, it is possible to have open treatment of a closed injury, though you almost never have closed treatment of an open fracture.

Because of the high risk of infection, open fractures are rarely repaired in the ED. In most cases, the ED physician would stabilize the patient and he or she would be sent to the operating room to have the injury repaired by a specialist, who would assume treatment for the patient and use the orthopedic codes. (See article, Use Orthopedic Codes Plus Modifier -54 to Get Paid for ED Fracture Care, page 3, ECA December 1998 issue.)

Codes indicating open treatment and manipulation are rarely used for the ED physicians service, notes DeHart.

Generally, ED physicians dont manipulate unless there is acute neurovascular compromise, DeHart notes. You may have a closed fracture with a one-degree bend to it, and the physician would put it in traction before putting on a castthat would be manipulation.

Fractures in which the wound is open or in which it must be opened surgically are most often treated by specialists in the operating room, Stimler indicates.

The majority of open fractures are treated by orthopedic, plastic, ENT, ophthalmologic, or oral surgery specialists, depending on which bone is fractured underlying the laceration or puncture wound, he says.

Tip: CPT coding guidelines listed at the introduction to the Musculoskeletal System subsection in the CPT Surgery section indicate definitions for open treatment, closed treatment, and percutaneous skeletal fixation as well as what is considered manipulation. It is helpful for coders to review these guidelines before assigning orthopedic codes for fracture repair.