ED Coding and Reimbursement Alert

Many EDs have trouble getting paid for treating fractures, sprains, and other orthopedic injuries. In fact, some departments have stopped submitting orthopedic codes altogether.

But, with a basic knowledge of coding requirements and good communication between ED coders, physicians, and the orthopedic specialists, EDs can get their deserved reimbursement for these services, say experts. For starters, ED coders must understand that orthopedic codes may be used only when the definitive or restorative care is delivered in the department. And, when orthopedic codes are used, the ED coder must append the -54 modifier. (See sections on restorative care and modifier -54 later in this article.)

In this issue we will only discuss coding for fracture care in the ED, though some of the principles are applicable to coding for dislocations and other orthopedic injuries. These subjects will be covered in future issues of EMCA.

Note: There are too many orthopedic codes for fracture treatment and stabilization to be completely listed in this issue. The codes can be found in the CPT under Surgery/Musculoskeletal System. Look under the specific bone or area that has been repaired.

Initial Stabilization vs. Definitive Treatment/Restorative Care

The first rule to remember is that orthopedic codes can be used only for care delivered in the ED if, and only if, the emergency physician provided the definitive treatment for the injury, not just the initial stabilization.

This is a tricky distinction at times, notes Betty Ann Price, BSN, RN, CCS-P, president, Professional Reimbursement & Coding Strategies, Inc., Palmetto, FL. Initial stabilization involves a temporary measure that allows for the restorative care performed by the orthopedist to be performed later. The definitive treatment, sometimes called restorative care, is care delivered that is directed at repairing the injury. In some cases the restorative care is the care provided by the ED physician. In these cases, orthopedic codes can be billed for the ED.

For example, in most cases, if a patient presented with a non-displaced fracture of the finger, the ED physician would typically splint the finger (orthopedic CPT codes, 29130-29131), initiate pain management, and refer the patient for follow-up with an orthopedist or their primary care physician.

Because a fractured finger would not normally require a cast, the splint would be the definitive treatment, says Price. Definitive treatment doesnt necessarily mean casting; it could be splinting, strapping, and/or pain management, she explains.

In cases of rib fractures, pain management is often the definitive treatment, since rib fractures are rarely strapped or splinted.

Note: Orthopedic codes for rib fractures are: 21800-closed treatment of rib fracture, uncomplicated, each; 21805- open treatment of rib fracture without fixation, each; 21810-treatment of rib fracture external fixation flail chest; 21820-closed treatment of sternum fracture, with or without skeletal fixation.

If the fracture was temporarily stabilized in the ED, but would require later definitive treatment by the orthopedist, the orthopedic codes should not be used in the ED. The initial stabilization treatment would be included in the E/M code for the visit (99281-99285).

For example, assume a patient presents with a fractured leg. The physician would order an x-ray (73550, radiologic examination, femur, anteroposterior and lateral views; 73590- radiologic examination, tibula and fibula, anteriolateral and posterior views), possibly splint the leg (29515-lower leg, 29505-upper leg), and refer the patient for follow-up with an orthopedist. The casting performed by the orthopedist would be the definitive treatment.

Very few ED physicians do casting, explains Price. The fracture care that wed be talking about in the ED is typically splinting, strapping, buddy tape, and/or pain management.

Few cases are cut and dried. There are many instances in which a coder would be unable to tell from the medical record whether or not the ED physician did deliver the definitive treatment, Price emphasizes.

Id recommend that the coder, on a case-by-case basis, take the chart to the physician and the two of them review it together. This will enable the doctor to ultimately make the call about whether he or she provided definitive treatment, Price states.

In many situations, however, it is simply not practical for a coder to speak with the ED physician on a case-by-case basis, notes Caral Edelberg, CPC, president and CEO, Medical Management Resources, an emergency medicine consulting firm in Jacksonville, FL.

The doctors need to be reminded to provide adequate documentation that will guide the coders, she explains. For example, if the physician were to write on the discharge instructions: referred for follow-up for restorative care within 24-48 hours, then the coder would know that the orthopedic codes cannot be used, and the ED physicians service is included in the E/M.

Long-bone fractures, those of the humerus, femur, tibula, and fibula are usually no-brainer coding decisions that will almost always require casting or definitive treatment by the orthopedist, Price advises.

Usually when you get in to the hand, the foot, and the heel areas, those are tricky. There are several small bones, some will require casting, some will just be treated with splinting or tape, she says.

There are also many other gray areas. For example, nasal fractures can sometimes frequently be treated with just a splint or tape, or simply pain management, but sometimes they require setting or surgical intervention by the ENT, she adds.

Modifier -54 Must Be Used in the ED

Orthopedic codes fall under the surgical package codes, which means they have a global period, notes Andrea Clark, RRA, CCS, CPCH, an independent health care consultant in Baltimore, MD.

This means that any pre- and postoperative treatment that occurs within the declared global time period is included in the treatment reported with the code.

For example,with Medicare, the majority of orthopedic codes have a 90-day global period.

ED physicians cannot report an orthopedic code without using the modifier -54 (surgical care only) to indicate that another physician will be providing follow-up care.

The orthopedist should bill the same orthopedic code with a -55 modifier (postoperative management only) to indicate that they provided the follow-up care.

Bill Splint Application in Addition to E/M

Even when the ED physician just provides initial stabilization, if he or she applies a splint, this application should be billed, say both Clark and Price.

If the ED physician provides the definitive treatment and the orthopedic code is used, then the splint application would, of course, be included in the global. But, when the service is initial stabilization and part of the E/M, the application should be billed separately, says Price.

For example, in the case of the patient with the fractured leg, if the ED physician splints the leg to stabilize it until the orthopedist can examine the fracture and apply the cast, the ED coder should bill for the application and attach a -25 modifier to the E/M code, she explains.

Both Clark and Price emphasize that the splint application can only be billed if the physician applies the spint. If the physician instructs a nurse or other provider to do this, then the service cannot be coded.

Price agrees, saying she is aware some people think that as long as the physician supervises, then it can be billed.

There has been some controversy about this, says Price. But I think this is something the physician needs to do. I believe the majority of experts agree that it should be a physician performing the service.