Orthopedic Coding Alert

When an orthopedist is called to the emergency department (ED) to treat an ankle injury, coders are often confused about which service they should charge for. First, the surgeon must make sure that the injury is properly diagnosed. Then, billing for ankle care becomes a question of Who bills for what?

Choosing the right diagnosis is the crucial first step. Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., says it is essential that the physician record more than a rule-out diagnosis in his or her notes. If the physician suspects an ankle fracture, Brink says, and the x-rays indicate just a sprain, he or she has to diagnose a sprain in the notes. The key, Brink adds, is to make sure there is a definitive diagnosis of the problem at the end of the day, rather than just an indication of what wasnt wrong. The rule-out will not work as a diagnosis. The orthopedists notes have to reflect what was actually wrong with the patient, even if the problem was less serious than originally suspected, as in the case of an ankle sprain rather than a fracture.

Common ED treatment scenarios for ankle fracture include:

1. Fractures requiring surgery. The ED physician asks an orthopedist to evaluate an ankle injury. The orthopedist diagnoses a displaced trimalleolar fracture, admits the patient to the hospital and schedules thepatient for open reduction and internal fixation (ORIF) later that day. The orthopedist reports the appropriate-level initial hospital care code (99221-99223) with modifier -57 (decision for surgery) appended to indicate that the decision for surgery was made during this encounter, and 27822 (open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 (... with fixation of posterior lip).

2. Fractures requiring closed treatment only. The ED physician asks an orthopedist to evaluate an ankle injury. The orthopedist examines the patient, reviews x-rays and diagnoses a displaced bimalleolar fracture. He or she performs a closed reduction with application of a short leg splint in the ED. The orthopedist reports the appropriate-level office or other outpatient consultation code (99241-99245) with modifier -57 appended, and also reports 27810 (closed treatment of bimalleolar ankle fracture, [including Potts]; with manipulation). No additional code is reported for application of the splint because, as CPT states, the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

The patient returns to the orthopedists office for follow-up 10 days later, and x-rays reveal that the fracture slipped. An ORIF is scheduled for the following day. The office encounter is [...]