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 [...]