ED Coding and Reimbursement Alert

Because orthopedic codes can seem like the whale that swallowed Jonah encompassing both preoperative and postoperative treatment while leaving fracture care stranded in a very small boat coding fractures requires the faultless use of confusing modifiers. When definitive or restorative treatment begins in the ED but follow-up care takes place elsewhere or at a later date, you can use modifiers to obtain legitimate reimbursement for the ED physician's effort.

"One thing I have to remind coders about is billing for any extra care that occurs in the ED" other than fracture care, says Tracie Christian, CCSP, CPC, director of coding at ProCode in Dallas.

The most frequently used codes for ED fracture care are 99281-99285, which indicate that the emergency physician has examined the injury but not provided a majority of an orthopedic surgical package service. Orthopedic codes fall under the "surgical package" category, which means they have a global period (typically of 90 days). Taping, pain management and E/M are bundled into the global surgical package. Any further service provided during the global period is also included in the global fee and cannot be billed separately.

That doesn't mean an emergency physician can't bill for both fracture care and an E/M service; however, the E/M code would need either the -25 modifier showing it was a separately identifiable service to the fracture care, or a -57 modifier showing it prompted the decision for surgery, if these are appropriate to the case and supported by chart documentation.

Orthopedic codes may be used only when the definitive or restorative care is delivered in the ED, and the ED coder must append modifier -54 (Surgical care only) to indicate that another physician will be providing follow-up care, Christian says. "If we leave -54 off, that implies that our physician is doing the follow-up care. Since that never happens, we must use modifier -54. On the flip side, the follow-up physician will use modifier -55 (Postoperative management only) to indicate they took care only of the postoperative management."

For pain management, or other treatments aimed at treating compromised blood supply or nerve activity, the ED physician typically reduces the fracture and then refers the patient to the orthopedist, which necessitates using modifier -54, says Carol Dodd, RHIT, senior coding consultant for MedQuist Coding and Information Services in Gibbsboro, N.J.

To guard against fraudulent double billing, the hospital's written guidelines "for coders and ED physicians should clearly delineate under what circumstances the ED physician may bill," Dodd says.