ED Coding and Reimbursement Alert

The first issue of ED Coding Alert (December 1998) covered the correct way to report ED physician treatment of orthopedic injurieswhen to use orthopedic codes vs. evaluation and management (E/M) codes.

However, when the ED physicians repair of a fracture or dislocation is reported with an orthopedic code, assigning the correct code is often a problem. For instance, the physician performs repair of a distal phalangeal fracture of a patients right index finger. Should the code assigned be 26750 (closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each); 26755 (with manipulation, each); 26756 (percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each); or 26765 (open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, each)?

In most cases, the coder must discern which service was performed from the EDs documentation of the patient encounter. Even when the documentation is thorough, coders will often need a basic knowledge of some clinical terms to assign the correct code. What is closed treatment? What is open treatment? What services constitute manipulation or internal or external fixation? (For some basic keys to understanding clinical terms for ED orthopedic coding, see box on page 75).

Editors Note: There are many different orthopedic codes listed in the Musculoskeletal System subsection of the CPT Surgery section. In this article, we will cover some general areas. Before assigning a particular code, be certain that it indicates the specific service performed. If you are uncertain, please check with the ED group or ED physician reporting the service.

Documentation Yields Clues to Treatment of Dislocations

Simple dislocations are often treated in the ED, with more complex open dislocations being stabilized and sent to a specialist for treatment, 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(ACEP) advisory committee on coding and nomenclature. Typical procedure is closed treatment of a shoulder dislocation, code 23650 (closed treatment of shoulder dislocation, with manipulation; without anesthesia), he says. Manipulations of dislocations, rather than involving two or more pieces of broken boneas in fracture manipulationmostly involve popping the joint back into place. This is known as reducing the dislocation.

Coders should look for application of digital blocks (for finger and toe dislocations) and documentation of the reduction in the procedure note to apply an orthopedic code, notes John Stimler, DO, FACEP, a practicing emergency physician in Jacksonville, FL, and a past president of the Florida Chapter of the ACEP.

Also, look for dislocation and repair in the differential and final diagnoses, he adds. Although not very common, some open dislocations are reduced in the ED with a consultation from an orthopedic specialist.

If the ED physician handles this type of injury, he
or she should discuss it with the consultants, document the conversation in the chart, document the procedure
and arrange for reasonable follow-up for the injury, Stimler says

Reduction of open dislocations also should include documentation of extensive irrigation of the injury prior to repair. If it is documented that the ED physician performed the irrigation, antiseptic cleansing, and repair of the wound, then he or she has provided the definitive care, he explains.

Coding the Application of Splints and Strapping

Knowing when to code for application of splints and strapping is confusing for many ED coders. First, many coders believe that the codes (29000-29590) cannot be applied if the physician himself does not apply the splint or strap.

However, DeHart advises that the codes can be used if the physician documents the effectiveness that the physician achieves with the splint, he says.

Although there are some payers who have gone one step forward unilaterally and said that they wont pay unless the physician places the splint himself, that is not the language we offered CPT, he explains.

DeHart, who is ACEPs representative to the CPT editorial panel, says it was not the panels intent to require the physician himself or herself to place the splint or strapping. However, Medicare and other payers have policies regarding reporting services that are not actually performed by the physician.

Coding and billing personnel should check individual policies to ensure their compliance, and they should appeal, if possible, any policies they feel are inconsistent with CPT rules.

Also, it is important to keep in mind that the application of splints, casts, and strapping is only separately reportable when the ED physician has not reported an orthopedic code for his service involving a fracture or dislocation. (See article in December 1998 issue of ED Coding Alert.)

If the physician performed only the stabilizing service for later treatment by a specialist, the ED physicians service should be reported with an E/M code indicating the level of service provided. The code for a splint or strap application would be reported separately. And, the -25 modifier (separately identifiable procedure or service performed on the same day) would be attached to the E/M code.

Use Care With Codes Indicating
With Anesthesia

There has been some debate about when codes indicating the use of anesthesia should be reported.

For example, 24600 is for treatment of closed elbow dislocation; without anesthesia, and 24605 is for the same treatment requiring anesthesia.

Some coders believe that the CPT language requires the patient to be placed under general anesthesia, while others believe that the use of local anesthetics and conscious sedation meet the code definition. The question is really, does it include conscious sedation, says DeHart. In my opinion, the work values (assigned by the Medicare RBRVS) generally interpret anesthesia to be spinal or general.

CPT provides a code for conscious sedation (99141) that can be reported separately from the orthopedic code, Stimler says.

However, Medicare does not recognize this code, and he advises that many billing and coding personnel, if they do not report conscious sedation separately, report the code that indicates with anesthesia to indicate the performance of conscious sedation along with the orthopedic procedure.

Note: The January 1999 issue of CPT Assistant contains an answer to a readers question that says the descriptor requiring anesthesia means requiring general anesthesia. However, many clinicians and coding consultants dispute this advice. We advise checking with your regional carrier representative or payer representative.