Orthopedic Coding Alert

Closed fractures can present mind-boggling coding challenges, with many different types of treatment available to the orthopedist who devotes much of his or her time treating these injuries. Knowing how to accurately report diagnosis and treatment codes, especially with E/M services and global packages in mind, is the first step to ethical reimbursement.

Fracture Primer

ICD-9 code descriptors specify a fracture's location and whether it is closed or open (e.g., 821.21, Fracture of femur, condyle, femoral, closed).
 
Closed fracture refers to a fracture where the skin remains intact: There is no broken skin or protruding bone at the fracture site. Code descriptors for closed fractures might include terms like "comminuted," "depressed," "elevated," "fissured," "greenstick," "impacted," "linear," "march," "simple," "slipped epiphysis," "spiral" or "unspecified." Use a closed fracture code unless the term "open" appears in the diagnostic statement.
 
Open fracture refers to a fracture where the skin is broken at or near the fracture site, often as a result of protruding bone. These injuries usually contain foreign material (dirt, gravel, glass or clothing fibers) and are prone to infection. Open fractures may also be referred to in ICD-9 as "compound," "infected," "missile," "puncture" or "with foreign body."
 
A fracture can be described using both closed and open fracture terminology, such as a compound, comminuted fracture of the femoral shaft. Code this type of fracture as open: 821.11 (Fracture of femur, shaft, open).
 
Physicians frequently describe a fracture with an associated dislocation, such as a fracture-dislocation of the left first tarsometatarsal joint. Code these fractures to the type of fracture and not the dislocation; in this case, 825.25 (Fracture of metatarsal bone[s], closed) would be appropriate.
 
CPT list the following categories of treatment:
 
Closed treatment is described in the Musculoskeletal System section of CPT 2002: "The fracture site is not surgically opened (exposed to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: 1) without manipulation 2) with manipulation 3) with or without traction." In these cases, the fracture is set through splinting, strapping or casting with or without the application of manual force or reduction. Some closed fractures can require skeletal traction, where pins or wires are attached to the bone. This is still closed treatment of a closed fracture, because the fracture site was not incised to access the bone.
 
Open treatment is also described: "The fracture is surgically opened (exposed to the external environment). In this instance, the fracture (bone ends) is visualized and internal fixation may be used." Open treatment or reductions of fractures almost always take place in the operating room under anesthesia, but closed treatments may occur in the emergency department, the office or another outpatient setting.
 
Percutaneous skeletal fixation involves the fracture being held in place or fixed via the placement of pins across the fracture site under x-ray control.
 
Do not assume that all open fractures require open treatment or that all closed fractures require closed treatment. As the Global Service Data 2002 guide of the American Academy of Orthopaedic Surgeons (AAOS) notes: "The type of fracture (e.g., open, compound, closed) does not have any coding correlation with the type of treatment (e.g., closed, open, percutaneous) provided. The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open or closed fractures and joint injuries."

Treatment and E/M Visits

Orthopedic coders differ on whether an E/M service is a legitimate charge along with closed fracture treatment without manipulation. Debra Lee, coding coordinator for Orlando Orthopedic Center in Orlando, Fla., has met with carrier resistance when the two services are billed together and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M code. "I am curious if there is any documentation on the use of the E/M code on the first visit when a code for a closed treatment of a fracture is billed on the same day," Lee says.
 
Joanne Simmons, CPC, surgery coordinator at Nemours Children's Clinic in Orlando, Fla., feels that the E/M charge with closed fractures is legitimate. "The appropriate way to code closed fractures, particularly if it's a new patient, is to bill the appropriate level of new patient E/M service with modifier -57 [Decision for surgery]," says Simmons. "Fracture codes are in the Surgery section of the book and fall into the global package scenario." A new or established patient with a wrist injury may report to the orthopedist not knowing whether he or she has a broken bone. The physician will perform all the aspects of a new or established E/M visit (99201-99215), order x-rays (which are billable separately) and then, when a fracture is diagnosed, apply a short arm cast. "It is unreasonable to expect a physician to go into a room, not evaluate the patient at all and just determine there's a fracture and treat it," Simmons adds. Consequently, the E/M charge is necessary for the physician to be compensated for performing an E/M service that is significant and separate from the global fracture treatment.
 
When you bill both the E/M service (with modifier -57 appended) and the fracture care code (e.g., 27818, Closed treatment of trimalleolar ankle fracture; with manipulation), documentation should remind the carrier that the fracture treatment is indeed a surgical procedure. As Simmons points out, the codes appear in the Surgery section of CPT 2002 and all have 90-day global periods. The inevitable downside is that some carriers' policies may specifically state that the initial hospital/office encounter is included in the global fracture treatment code, in which case modifier -57 is a moot point until the carrier contract can be renegotiated.
 
Global Service Considerations

Coders who report closed fracture care codes should bear in mind what is included with the global service. The AAOS Guide to CPT Coding in Orthopaedic Surgery points out that all supplies and medications including casts, splints and strapping (when provided by the practice and not in a hospital or surgery center) are separately billable, as are complicated wound closure (e.g., 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less), debridement (11010-11012), application of external fixation (unless included in the code description) and arthrocentesis (20600*-20610*) for relief of pain. Replacement casting during the 90-day period can be reported separately using one of the codes from the Application of Casts and Strapping section (29000-29799), as can subsequent x-rays taken in the physician's office during the postoperative period.
 
Included in the 90-day global period are the initial treatment of the fracture (with or without cast application) and all follow-up visits related to treatment of the fracture, as well as removal of the initial cast.