ED Coding and Reimbursement Alert

Question: A 30-year-old female presents to a rural ED with several injuries after the all-terrain vehicle she was driving overturned. During a level-five ED E/M service, the physician diagnoses a fractured metacarpal shaft in her left hand and a fractured left femur. The ED physician provides closed manipulative treatment for each fracture. How should I code this scenario?

Tennessee Subscriber

Answer: Report the most severe fracture first, and make sure that you append a surgical modifier to the treatment codes. To make things easier, we'll list the appropriate CPT codes first, then the ICD-9 codes.

CPT coding: On the claim, report the following:

• 27502 (Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction) for the femur treatment

• 26600 (Closed treatment of metacarpal fracture, single; without manipulation, each bone) for the metacarpal treatment

• modifier 54 (Surgical care only) appended to 27502 and 26600 to show that you are coding only for the fracture treatment (If the ED physician is, for some reason, providing all the follow-up care for the patient, then you can leave modifier 54 off the claim.)

• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99285 to show that the E/M was a separate service from the fracture care.

Remember: Multiple-surgery rules will apply to this claim, so be sure to report the higher-paying code first. Payers will reimburse the first procedure at 100 percent, and the second and subsequent procedures at 50 percent.

ICD-9 coding: On the claim, report the following:

• 821.01 (Fracture of other and unspecified parts of femur; shaft or unspecified part, closed; shaft) linked to 27502 and 99285 to represent the patient's femur fracture

• 815.03 (Fracture of metacarpal bone[s]; closed; shaft of metacarpal bone[s]) linked to 26600 and 99285 to represent the patient's metacarpal fracture

• E821.0 (Nontraffic accident involving other off-road motor vehicle; driver of motor vehicle other than motorcycle) linked to 27502, 26600, and 99285 to represent the cause of the patient's injuries.