Orthopedic Coding Alert

Best bet: Confirm closed, open, or percutaneous treatment.

Calcaneal fractures (heel bone fractures) are the most common tarsal fractures and you may be used to coding them a certain way -- but if you’re not following the advice below, you could be compounding errors and leaving deserved pay on the table for these services.

Omit Casting with Closed Fracture Treatment

Coding scenario: A patient reports to your orthopedist after a fall and the surgeon confirms a calcaneal fracture. The surgeon performs plantar displacement of the forefoot and hindfoot to reduce the fracture and then applies a short cast to stabilize the fracture.

You report code 28405 (Closed treatment of calcaneal fracture; with manipulation) for this service. You do not separately report 29405 (Application of short leg cast [below knee to toes]) for the cast application, as this is included in the treatment code 28405. "You cannot bill 28405 and 29405 together," confirms Josie Dunn, CPC, Department of Orthopedics, University of Maryland Faculty Practices, Maryland. "Cast application or strapping (including removal) is only reported as a replacement procedure or when the cast application or strapping is an initial service performed without a restorative treatment or procedure. You may bill the cast if your surgeon applies a second casting."

Keep in mind: You may report the casting services (cast application or modifications) for subsequent encounters requiring cast care in the global. "The 58 (Staged or related procedure or service by the same physician during the postoperative period) modifier would be appended to the cast-related services in the global period to indicate a staged or related service," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington."Supplies can be billed by the provider at the time of the initial cast application, if the supplies are provided by the provider or care center."

If your surgeon does no manipulation of the calcaneal fracture, which is more common, you report code 28400 (Closed treatment of calcaneal fracture; without manipulation).

Turn To Specific Code for Percutaneous Fixation

In a patient with inadequate soft tissues, for example in a diabetic patient, your surgeon may opt for external fixation to stabilize the calcaneal fracture. You will need to carefully read through the operative note to confirm that your surgeon adopted a percutaneous approach to fix the fracture.

Example: You may read that for a patient diagnosed with calcaneal fracture, your surgeon inserted distraction screws to externally fix across the calcaneal tuberosity, distal tibia, and the talus. In addition, your surgeon may insert a cannulated screw from the lateral to the medial side into the sustentaculum tali. Your surgeon may use a lateral pin to manipulate the fracture fragments.

In this case, you confirm the percutaneous fixation of the calcaneal fracture and report code 28406 (Percutaneous skeletal fixation of calcaneal fracture, with manipulation).

"The percutaneous fixation requires pins to be placed through the skin and into the bone to hold the fracture in place once the fracture has been aligned by the surgeon," says Tamela Kyle, CPC, Department of Orthopedics, University of Maryland, Maryland. "Fracture alignment is accomplished by manipulation under fluoroscopy or with X-rays. Pin placement is accomplished through small holes or a small incision (usually called a stab incision) in the skin that allows pins to be pushed through the skin and soft tissue into the bone once the surgeon is satisfied with the alignment," she adds. "The fracture area is not surgically opened to the environment and the surgeon would not have visual contact with the fracture. Once the pins are in place, a cast, splint or brace is applied."

Do this: You need to confirm direct visualization versus percutaneous approach under fluoroscopy. "Coders should be aware that the fluoroscopic guidance is included in the global package per AAOS and NCCI guidelines and is not separately reported unless hard or electronic copies of the films are taken for the patient file with a separate and distinct X-ray reading," says Stumpf. "Code 28415 (Open treatment of calcaneal fracture, includes internal fixation, when performed) is reported for open fracture treatment, under direct visualization that may include application of hardware. IM rod is also considered open fracture treatment per CPT^®/AMA guidelines."

Include Internal fixation in Open Treatment

When your surgeon adopts an open approach to treat the calcaneal fracture, you report code 28415. Note that this code is inclusive of any internal fixation that your surgeon does. "Dissection is required and the surgeon would also have direct visualization of the fracture," says Kyle. "The surgeon reduces the fracture into correct alignment, which may require putting fracture pieces or fragments into their correct position and applies a fixation device such as a plate with screws or pins if needed. The incision site is irrigated and closed in layers."

Coding case: Take a look at the following op note for an open treatment:

"The articular fracture fragments were exposed and a large threaded Steinman pin was placed through posterior superior portion of the calcaneal tuberosity, and longitudinal traction was applied through the pin. The tuberosity fragment was disimpacted to reduce the sustentacular fragment anteromedially which was displaced out of its normal position. The anterolateral fragment was reduced and fixed with a 3.5 mm cortical screw. Finally, the tuberosity fragment was moved and brought out of varus."

"Next was the articular reconstruction after restoring the relation between the sustentaculum and tuberosity fragments. The posterior facet was examined and the depressed fracture fragments were depressed en masse from the body of the calcaneum. A threaded Steinman pin was inserted through the posterior inferior corner of the calcaneus. This went across the posterior facet and into the talar body and helped to stabilize the valgus reduction. A finger was probed around the posterior facet and there was no step off between the tuberosity and the cuboid. Another threaded Steinman pin was passed through the posterior calcaneus."

Look For Grafts

If your surgeon uses as bone graft for reconstruction, you report code 28420 (Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft [includes obtaining graft]).

Both 28415 and 28420 involve an open approach. "Dissection is required to reach the fracture site. Direct visualization allows the physician to determine if bone grafting will be required," says Kyle. "To use code 28420, the surgeon must harvest bone through a separate incision made over the iliac crest or other donor area. Bone is harvested and then placed into the fracture site or defect. The surgeon irrigates and closes the donor site.  Once the harvested bone graft is placed in the defect, the surgeon would then apply any internal fixation device (if needed) to the fracture, then irrigate and close in layers," she adds.  "However, code 28415 would be used if bone is harvested from a cadaver or if only synthetic bone grafting material such as bone matrix is used."

You need to appropriately document that the graft was a distinct separate procedure. Here is what the AAOS has to say about bone graft reporting:

The rules for using the bone harvesting codes (20900, 20902) and the codes for harvesting other grafts are often misunderstood. These codes are only to be reported when the graft is harvested from a "separate" site through a separate skin or separate fascial incision, and "when the graft is not already listed as part of the basic procedure," according to notes at the beginning of the Musculoskeletal System Section of the CPT^® Manual.http://www2.aaos.org/bulletin/apr05/code.asp

Example: Stumpf shares an example from an operative note:

"A lateral incision was made in the hindfoot and was deepened to the bone up to the subtalar joint. The sural nerve was isolated and protected. The calcaneal fracture fragments were mobilized to anatomic position and a calcaneal plate was applied to maintain the reduction of the fracture fragments. A separate incision was made at the iliac crest and a large bone graft was obtained. The iliac crest wound was irrigated and closed in layers. Bone graft was packed in the fracture site prior to plate application to fill the gaps. The wound was irrigated and closed in layers."

What to code: "The coder should note that the bone graft harvest is not separately reported with 28420. The vignette for 28420 describes a separate site bone marrow harvest," says Stumpf. "Carriers will likely consider same site bone graft harvest to be included in code 28415."

Be Clear on 28406 Versus 28415

Do ensure you check for an open or percutaneous approach. "The difference between codes 28406 and 28415 is the approach required for treatment," says Kyle. "Percutaneous fixation reflects management of the fracture without direct visualization of the fracture fragments with placement of fixation across the fracture site," says Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. "When this procedure is performed, there will generally be documentation of the use of imaging such as C-arm for placement and visualization of the fracture."

Report IM Nail as Open Treatment

When your surgeon does an IM nailing, you report it as an open approach with 28415. "The fracture is either surgically exposed to the external environment and the fracture ends directly visualized or the fracture is opened remotely and fixation placed with an intramedullary nail," says Woodward.  "IM nailing would be done for fractures of long bones and would only be used if there was not already a code defining reduction with placement of IM nail."