ED Coding and Reimbursement Alert

Question: If I report a code for definitive care of a fracture, does it include evaluation and management services? Should I just report the CPT code for the fracture and no E/M code?             
 
Alabama Subscriber

Answer: Rarely is it appropriate to report only a fracture care code without an accompanying E/M code in the emergency department (ED). For starters, most fracture treatment requires a history regarding the mechanism of injury, a thorough physical exam, and a thorough assessment of the patient. And the physician must perform a fairly detailed medical history, as well as other elements of E/M services.

Unlike fracture treatment by an orthopedist, in which another physician has already prescreened and diagnosed the patient and passed on the knowledge that the injury is isolated, the ED physician is seeing the patient for the first time. Because it is her first encounter with the patient, she must screen for other injuries or medical problems. Even in the most straightforward cases, the orthopedist is armed with more information from the start.

Example: The information the orthopedist has looks like this: "Patient presenting with x-rays from yesterday's visit to the ED. Radiology reports non-displaced distal radius fracture." The ED physician, on the other hand, receives the following information: "44- year-old male fell on the ice. Patient complains of wrist and arm pain, mild numbness in fingers, and contusion to right hip."

Because the ED doctor is the first to see the patient, she is responsible for a complete assessment, which means answering questions like these:

Was the fall mechanical or did the patient faint?

Are there other injuries?

What medical comorbidities may play a role in the patient's condition? Addressing these global uncertainties means that the amount of work and time required of the ED physician to examine the patient thoroughly before treatment differs greatly from the work required of the orthopedist. This more global assessment of the patient with regard to history, physical exam, and medical decision making usually justifies separately reporting an E/M code (99281-99285) for the ED physician's work.