Orthopedic Coding Alert

Incision key in coding these scenarios correctly.

When patients report to the orthopedist for repair to rib fractures, coding can get complicated if you don't know certain vital coding facts that will ultimately lead you to the correct code.

Help's here: Follow this FAQ on some of the most-asked rib fracture coding questions. With answers from Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for Oklahoma Sports Orthopedics Institute in Norman; and Denise Paige, CPC, COSC,  an orthopedic coder with Bright Health Physicians in Whittier, California, you're sure to crack every rib fracture coding conundrum.

Q: What is the definition of open rib fracture treatment?

A: In an open treatment, the physician "gains access to the fractured rib through an open incision made in the area of skin over the rib," Stilley explains.

Paige concurs, adding "open treatment would mean creating or extending an already open wound to allow access to reduce and/or add internal fixation for the fractures."

Coding: You'll report open rib fracture treatment with one of the following codes, depending on the specifics of the encounter:

• 21811 - Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visual­ization when performed, unilateral; 1-3 ribs 
• 21812 - ... 4-6 ribs
• 21813 - ... 7 or more ribs.

Q: What is internal fixation, and is it REQUIRED to report 21811-21813?

"Internal fixation describes the use of some type of hardware – nails, screws, plates, or wires - to stabilize the fracture," Stilley explains. Since the descriptors for 21811-21813 state "with internal fixation - there is no comma, which is interpreted as being required for the code," she says.

As a counterpoint, Stilley offers the part of the 21811-21813 descriptors that mention thoracoscopic visualization. In this descriptor thoracoscopic visualization isn't required; the comma in the descriptor "indicates this is not required, but is included if performed," says Stilley.

Q: Can you ever bill for anything separately from 21811-21813? X-rays, etc.?

A: "Interoperative x-rays would be considered part of the surgical package and not separately billable by the surgeon," explains Paige. Further, "open treatment of rib fractures would typically open a 90-day global period, and the same guidelines for fracture care coding would apply regarding E/M [evaluation and management] codes, X-rays and supplies."

Q: How does "closed treatment" of rib fractures differ from open treatment?

When the orthopedist performs closed treatment for a rib fracture, she manipulates the fracture from outside the body to realign the rib that is misaligned or separated (no incisions). The provider might tape or strap the fracture in place, but there would be no "open" treatment elements present.

Coding: Coding for a closed rib fracture depends on the type of fracture. "CPT^® Instructional notes state to use the appropriate E/M code for treatment of an uncomplicated rib fracture," relays Stilley. "For external rib fixation, use 21899 [Unlisted procedure, neck or thorax]."

Example 1: The provider performs treatment of an uncomplicated rib fracture during an office E/M visit for an established patient. Encounter notes indicate a level-four E/M service. For this claim, you'd report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...).

Example 2: The provider performs external rib fixation for an uncomplicated rib fracture. For this encounter, you'd report 21899.