Orthopedic Coding Alert

Asking the right questions when treating a child for injuries resulting from a fall will lead to the appropriate billing codes. The injury, the site of the fall and the place of treatment determine the code(s) to use.

A child falls from a tree, and an x-ray reveals an undisplaced fracture of the arm. Chances are, that brief sketch is enough to prompt a coder to begin asking a lot of questions.

Thats a good thing, of course. The more questions, the more answers, which leads to a more complete picture the coder can produce for a payer. And the better chance of receiving optimum reimbursement.

Pat Maccariella, RRA, CCS, of United Audit Systems Inc. in Myrtle Beach, SC, says the first question she has when she reads the sentence is, Which bone in the arm is displaced?

There is diagnosis code 818.0 (ill-defined fractures of upper limb; closed) if we dont have the site in the arm. But Id ask the physician and try to get the exact place, the distal radius for example.

Maccariella explains she would not stop her queries or her coding there. She would use E884.9 (other fall from one level to another), which clarifies the type of fall (fall from: embankment, haystack, stationary vehicle, tree).

Look carefully at the choices for external causes. Some falls garner a unique code. Code E881.0 (fall from a ladder) is an example.

Office Treatment or Emergency Department?

Depending on the setting where the patient receives attention, very different things might happen in terms of coding. Is the physician going to be following up with surgery? asks Maccariella. If yes, the cast [if used] will be bundled with the surgery.

If a cast is going to be the singular treatment, a provider can bill for the cast application. Maccariella says it is important to identify the type of cast, whether a long arm (29065), short arm (29075) or hand and lower forearm (29085). The length of the cast determines the code, she says.

Note: Cast immobilization devices codes fall into a range between 29000 and 29750 in the CPT system.

And Id use 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies or materials provided]) to code for casting materials.

When treatment occurs in the emergency department (ED), a physician often aims to rule out head injury. If this is an ER, and the physician looks for head injury, thats evaluation and management, and Id bill for it by using a -25 modifier and the appropriate 99000 code.

Note: The -25 modifier designates a significant, separately identifiable E/M service by the same physician on the day of a procedure. It applies even when the same eventin this case a fall from a treeprecipitated the separate E/M for head injury.

Thorough Coding in Office or ED
Includes Radiologic Exam

Whether in an office or ED setting, an orthopedist can bill for the radiologic exam, most likely 73090 (radiologic exam; forearm, anteroposterior and lateral views). The 73090 is a global code and indicates the physician conducted and interpreted the radiology exam.

If a hospital radiology group does the radiologic exam (73090), an ED physician treating the child might still be able to code for reimbursement by using a modifier -26 (professional component) with 73090.

HCFA specifies that if a radiologist and the ED physician have both offered an interpretation and report on the x-ray, the one who directly contributed to the diagnosis and treatment of the patient should be paid.

Note: Medicare takes a more cavalier approach than HCFA and pays whichever claim it gets first.

Distal Radius Coding

Because Maccariella mentions a fracture of the distal end of the radius as one of many possibilities, take it as an example for a quick coding review. ICD 813.42 (other fractures of distal end of radius [alone]; Dupuytrens fracture, radius; radius, lower end) reports the diagnosis.

Code 25600 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation) fits if a splint is applied.

Note: See the related article Getting Reimbursed for Applying Casts and Splints on page 93 of this issue.

Observing, Integrating and
Educating for Proper Coding

The physicians report should be written so anyone who comes along can get the full story says Maccariella. The physician knows precisely what part of the bone needs attention and that should be in the report.

Helping physicians envision everything that ought to be in a report is part of the service that Maccariella provides to clients. She sometimes will shadow doctors in the ER to see what they are missing.

That is, what can be billed if it was recorded. She then meets with physicians to talk about what she saw and what they actually put on record.

The same is done in office settings. The more specificity physicians can supply, the more detailed a picture coders can draw. And that is what Maccariella helps physicians understand.

Observation, integration between the treatment arena and the coding office and education are all crucial elements of Maccariellas job. Asking questions is where it all begins.