Orthopedic Coding Alert

6 steps capture exclusions to get you the right code combo.

Guest columnist: Annette Grady, CPC, CPC-H, CPC-P, CCS-P, OS With fracture type, treatment, debridement, intent, documentation, and materials all vying for your attention, you can easily land on the wrong surgical code -- or billing method, or even overlook an allowed charge. Make achieving the correct code combination less of a feat by taking these steps.

Step 1: Identify Fracture Treatment Type

The most important thing to remember about fracture care is that the type of fracture does not have any coding correlation with the type of treatment that is provided. For example, an open/compound fracture can be treated by closed means, or vice versa.

An orthopod may employ these fracture treatment types:

Closed treatment: The fracture site is not surgically opened (exposed to the external environment and directly visible). Closed treatments can be with or without manipulation and/or traction.

Open treatment: The fracture is surgically opened and visible (internal fixation may or may not be used), or the fractured bone is opened remotely from the fracture site to insert an intramedullary (IM) nail across the fracture site. To code the open treatment, a surgical opening needs to be made.

Percutaneous skeletal fixation: The physician places a fixation across the fracture site,usually under x-ray imaging such as fluoroscopy, but the fracture fragments are not visible.

Step 2: Determine External or Internal Fixation

You also need to consider external and internal fixation when choosing a surgical fracture code. The reimbursement for fracture fixation, whether internal or external, is frequently included in the CPT code. Use codes for external fixation when external fixation is not listed as part of the basic procedure.

External fixator: This is a device that is fitted to the outside of the limb that is fixed securely using pins or wires to the bone fragments. The external fixator is used to support the bone while it is healing. External fixation usually allows joints to move normally while the bone is healing. This may shorten a patients hospital stay shorter, and help him get back to his normal life as soon as possible.

The operated limbs mobility amount or weight bearing depends on which bones are affected and the type of fracture. CPT 2008 made language revisions to exclude external fixation and include internal fixation, when performed in the surgical fracture care codes. This language revision helped to clarify what type of fixation was included and not included in the procedure. For example, 25608 (Open treatment of distal radial  intraarticular fracture or epiphyseal separation; with internal fixation of 2 fragments) includes internal fixation, but would not include external fixation.

Remember this: The use of both internal and external fixation represents more work. Therefore, if internal fixation is performed, external fixation may be coded separately as 20690 (Application of a uniplane [pins or wires in one plane] unilateral, external fixation system) or 20692 (Application of a multiplane [pins or wires in more than one plane], unilateral, external fixation system [e.g.,Ilizarov, Montecelli type]).

Internal fixation: This uses a variety of different types of hardware, such as plates, screws, nails, and wires to stabilize the fracture. Internal fixation is a fracture reduction procedure that results in fracture stabilization. When internal fixation is performed the fracture site is opened.

Percutaneous skeletal fixation is an internal fixation method that also requires direct exposure of the fracture site. This method is performed with fluoroscopic imaging and the surgeon will insert hardware such as screws, Steinmann pins, or Kirschner wires into the bones across the fracture site for stabilization.

Intramedullary nailing or rodding is another internal fixation method that helps stabilize the fracture, the most common type of IM rodding is performed on the femur.

The fracture will be manipulated into correct position using radiographic imaging, and the surgeon will approach proximal or distal to the fracture site and thread a nail down the intramedullary canal, through the bone across the fracture site. Many times interlocking screws are placed at angles to the nail to further stabilize the fracture. These procedures have separate codes throughout CPTs musculoskeletal surgery section such as 27245 (Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage).

Skin or skeletal traction requires force to stabilize and reinforce the fracture fragments. Application of traction causes the muscles as internal splints to maintain the bones in proper alignment. Skin traction applies longitudinal force on a limb with felt, foam, or a strapping apparatus.Skeletal traction uses force by a pin, wire, screw or clamp that penetrates the bone.

Step 3: Check for Separately Codeable Debridement

Consider debridement a separate procedure only when gross contamination requires prolonged cleansing, and documentation must support that an appreciable amount of devitalized or contaminated tissue is removed or carried out separately without primary closure. Report debridement for these conditions with: 11040 (Debridement; skin, partial thickness) and 11044 (Debridement; skin, full thickness).

If the fracture is open, it may be necessary to clean and prepare the fracture prior to any restorative treatment and/or stabilization of the bone. The wound site may be contaminated with foreign material such as glass, dirt, grass, metal, gravel, etc. Open fracture debridement is separately reported under these circumstances and reported with 11010 (Debridement including removal of foreign material associated with open fracture[s] and/or dislocations[s]; skin and subcutaneous tissues) and 11012 (... skin and subcutaneous tissues, muscle fascia, muscle, and bone).

Step 4: 3 Questions Determine Fracture Care Intent

Fracture care intent is the next step to determine yourcode choice. Are you going to code global or itemized?

Physicians are given both options.

Here are some key questions to ask:

" Will restorative treatment or procedure(s) be performed?

" Will the same physician assume all subsequent fracture care?

" Are there risks associated with the fracture?

Global reporting will include the initial cast application and all professional services for a 90-day period. Your physician should not report further reassessment separately.You may report items separately such as: further castings, splinting, radiographs, and supplies. These items are not included in the global period.

Itemized reporting utilizes the evaluation and management code section rather than a surgical fracture care code.In addition, the initial cast application and/or splinting is also reported with the evaluation and management code.

Relative Value Unit reimbursement for both is similar.Variances will occur only when a patient exceeds more than three follow-up visits or never returns for follow-up.

Many times the fractures type and severity also determine this. For example, if a patient suffers a scaphoid fracture (814.01), she may exceed more than the allowed two follow-up visits within the 90-day global period.Therefore, E/M coding (99212-99215, Office or Other Outpatient Services) would be more advantageous.

But, if the patient has a simple fracture distal phalanx (816.03), she may return only one time -- in this circumstance the surgical fracture code (26750) is better.

Reality: In most cases, fracture care code reimbursement and E/M code reimbursement are equivalent.

You should determine if your contracted insurance payers have key policies on fracture coding and its integralcomponents and verify policies you already have. In addition, determine if the payer has larger co-payments or deductibles for surgical codes versus E/M codes. The physician should choose the method that meets his/her contractual obligation and complies with authoritative coding hierarchy.

Step 5: Look for Procedure, E/M Supporting Documentation

Documentation should also reflect the type of care and treatment. Key items in the initial assessment should have the neurologic and vascular status clinically assessed and documented. Documentation should also note the realignment of the broken limb segment and/or assessment of the broken segment -- for instance, what type of immobilizing was performed on the fracture? Splinting is critical in providing symptomatic relief for the patient. It also prevents potential neurologic, vascular injury and further injury to the local soft tissues.

When reporting the global method of fracture care, an E/M service may also be reported. Documentation must support a decision for surgery (modifier 57) and/or a separate identifiable service (modifier 25, Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Step 6: Remember to Code for Materials

With either method, do not forget to report additional supplies of casting materials.CMS has approximately 50 Q HCPCS codes that address supply issues with casting/splinting applications. The HCPCS level-II manual offers A codes. CPT contains 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).

Check with payers to determine the best reporting mechanism for supplies. Documentation should also support medical necessity of any future cast application/repairs/replacement as some payers will allow only one cast application.

Be Aware of RVU Revisions

Watch for future changes in fracture code RVUs as they have been brought to attention by CMS. They were briefly mentioned in last years final rule for the physician fee schedule but were tabled for future topic. This is a clear indication that change and further defined guidelines may come into future play for fracturesurgical codes.

Guest Author Bio: Annette Grady, CPC, CPC-H, CPC-P, CCS-P, OS, has over 30 years of experience in healthcare coding and reimbursement. She is the former Director of Reimbursement for a large orthopedic group and consultant for a large Midwestern consulting/CPA firm. She has proficiency in CPT, ICD-9 CM, and HCPCS coding for Orthopedics, ASCs, Spine, Plastic/Reconstructive, Hand, and Family Practice. Annette has performed many surgery and E/M chart review audits. She is a well-known author and has published multiple articles in Outpatient Surgery Magazine, AAOS-bulletin,NASS Spineline, Physician Practice Management, and many other publications. In addition, Annette is a National Speaker for various organizations: AAPC, BONES Society, AmSurg ASC Corp, ND MGMA, UND Medical School, Montana Coding Focus Group, and many state medical societies.