EM Coding Alert

Hold on to your $ when choosing a fracture or casting code.

When your physician sees a patient with a fracture, determining whether you should report an office visit code or a fracture care code can be just as complicated as the break itself. The criteria for using an E/M code versus a fracture care code are distinctly separate and knowing the difference is critical to capturing proper payment. 

Follow these expert tips to ensure you choose correctly every time. 

Start With Knowing What Adds Up to Fracture Care

If all three of the criteria mentioned below are met in the patient’s presentation, you will code for fracture care:

• Your physician sees the patient for her initial visit for the injury. (For example, 826.x [Fracture of one or more phalanges of foot]) and 838.xx (Dislocation of foot). The injury is recent enough that it has not already healed on its own.
• Your patient has not had surgery for this injury by another physician in a different practice. (For instance, if the patient was injured while on vacation, had surgery and now is home and seeking follow-up, you cannot bill fracture care).
• Your physician provides a restorative treatment or procedure and plans to care for this injury for the next 90 days.

Example: “The emergency room physician sometimes is the first person to see a patient for treatment,” says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc. in Spring Lake, N.J. “He takes an x-ray, diagnoses a closed fracture (usually closed since open would require surgery at that time), and may even try manipulation to realign fracture and splints extremity. Then he calls the orthopedic doctor or he advises the patient to call an orthopedic doctor’s office to schedule an appointment for further treatment — either manipulation and casting or closed reduction under anesthesia,” further explains Brink. The emergency room physician would use a fracture care code.

Additionally: “If the initial treating physician is not providing the follow up care of the fracture, the appropriate global fracture care code from the 20000 series of codes (25500 [Closed treatment of radial shaft fracture; without manipulation]) may be used with modifier 54 (Surgical care only),”adds Jackie Mehalich, RN, CPC, CPC-H, physician compliance auditor at Allegheny Health Network in Pittsburgh, Pa. 

If you’re not able to use the global fracture care coding process, there are other possible coding options when the initial treating physician is not providing the follow-up care, Mehalich explains:

• An E/M code (new or established depending on the time between visits)
• A casting, splinting, or strapping code
• When a physician initiates the care of the fracture and also provides all of the post-operative care of the patient, either following her own initial evaluation or on referral by another physician, she may bill the appropriate global fracture care code from the 20000 series without a modifier.

Look for 1 of 6 Criteria to Signal Using an E/M Code 

If any of the criteria listed below are met, consider coding for an E/M service for new or existing patients (99201-99215 [Office or other outpatient visit for the evaluation and management  …]) instead of the fracture care: 

• The fracture is old
• There is a nonunion of the fracture
• The fracture has healed or mostly healed
• The physician doesn’t provide a restorative treatment or procedure for which he goes to assume follow-up care for the next 90 days
• The physician doesn’t recommend follow-up visits
• The physician refers the patient for a more extensive procedure, like open treatment with or without fixation.

You should also consider coding for the application of casts and strapping using a code in the 29000-29799 range along with the E/M code.

Example: A physician performs and clearly documents a level-two E/M service and then straps an established patient’s fractured ankle that is partially healed, clearly documenting the strapping.

What to do: On the claim, report the following:

• 29540 — Strapping, ankle and/or foot
• 99212 — Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision making ...

Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.) to the 99212 showing that the E/M and strapping were separate services.

Pitfall: Thinking that you can use 99070 (Supplies and materials [except spectacles], provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) with 99212 in this case? The AMA and Medicare already factor essential supplies into a code’s values on the physician fee schedule, so you shouldn’t separately bill 99070.

Correct Coding Depends on Well-Documented Fracture Treatment

Your physician’s clear documentation of the fracture treatment he performed is crucial for your accurate coding. The record needs to state whether he performed open or closed manipulation. If the report isn’t clear, there are words to look for to help you: align, reduce, reset, manipulation, or closed reduction.

“Correct coding dictates that you code for the procedure the provider performed and documented,” Brink says. “Therefore, if some type of fracture treatment, whether manipulation, closed or open, was performed and documented, then that is what is charged/coded with fracture diagnosis supporting medical necessity. It would be inaccurate coding to code for an E/M and strapping or cast application, when fracture required manipulation, closed or open treatment, and then continue to code for E/Ms in follow-up care,” continues Brink.

Choose Fracture or Casting Code When There’s No E/M

You can’t always code an E/M and an applicable casting code. You may not have a reportable E/M. 

Example: A parent brings in a child that has stubbed her big toe. The physician looks at the X-ray and makes a diagnosis of a closed fracture. He straps the toe to the adjacent toe and tells the parent to have the child wear a protective shoe for a while. The physician cannot report a separate E/M service.

What to do: You have two options. You can either code with 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation) or you can code with 29550 (Strapping; toes). Experts say that both options describe the same work performed by a physician. The physician isn’t referring the patient to an orthopedist and the physician may see the patient for follow-up. With the 29550, follow up E/M services are also billable.

If you report fracture care with 28490, which has 4.13 RVUs and 90 global days, you would be paid $147.94. If you report a casting code 29550 with .88 RVUs, you get paid $31.52. Given that the difference is $116.42, you should consider reporting the fracture care code if the record supports doing so. The thorough documentation of the physician will guide you to the appropriate code.

“If the documentation is complete, the better way to code would be to bill the E/M for the visit,” suggests Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Alleghany Health Network in Pittsburgh, Pa. “If the X-ray was performed in the office and is to be billed by the office, that would not be added to the medical decision-making component, but rather billed separately. If it was performed elsewhere and just reviewed, it can be added into the decision-making component.”