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 [...]