Orthopedic Coding Alert

Find out what manipulation means and test yourself with two scenarios.

When your orthopedist performs fracture care, be sure to take advantage of manipulation opportunity or you could be losing out on your reimbursement without the appropriate manipulation knowledge.

Say the orthopedist performs closed treatment on a fractured fibula; if she uses manipulation, the service is worth about $119 more than a non-manipulation encounter. However, you should consider several factors before you decide a manipulation warrants the treatment. Arm yourself with these 3 tips to get you started.

1. Know What You're Dealing With

You can't support your claim if you have no idea what manipulation is. "Manipulation involves reduction or attempted reduction of the fracture or dislocation," explains Gerri Walk, RHIA, CCS-P, senior manager for Baltimore's Health Record Services Corporation.

Orthopedists would typically perform a "closed" manipulation, which occurs when "the physician is repositioning or relocating a displaced closed fracture back to the correct anatomical position without surgically opening it. Just the same, there is such a thing as "open" manipulation.

Payout: From our earlier example of closed treatment on a fractured fibula, you would consider two CPTs to report the treatment: 27780 (Closed treatment of proximal fibula or shaft fracture; without manipulation) and 27781 (... with manipulation). CPT 27780 pays about $272.49 (7.39 relative value units [RVUs] multiplied by the 2010 Medicare conversion rate of 36.8729); while 27781, with 10.61 RVUs, pays about $391.22.

2. Key Words Give Away Manipulation Procedure

If you rely on physician's notes to give evidence of manipulation, you have a chance of being misled.

Why: The word "manipulation" does not make its way into physician encounter notes very often.

Generally, what you should look for is the term 'closed reduction,' which is used for non-operative treatment of fractures that are treated without surgery. Other terms that might help identify a manipulation procedure include 'reduce,' 'align,' and 'reset'.

3. Spot Manipulation Evidence In These Examples

Only when you learn to read your physician's notes between the lines will you be able to tell a manipulative treatment from a nonmanipulative one. Consider these two scenarios:

Example 1: A 20-year-old new patient reports to the orthopedist with an injured right toe; the injury happened when an opponent in a football game tackled him. The physician documents a level-three E/M, which includes a foot X-ray and administration of pain medication. After reviewing the X-ray the physician diagnoses a distal interphalangeal joint dislocation (DIPJ) of the toe. The physician notes that he "reduced and reset toe."

This is an example of manipulative care. On the claim, you would report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making) for the E/M
• modifier 57 (Decision for surgery) appended to show that the E/M led to the fracture treatment
• 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each)
• 826.0 (Closed fracture of one or more phalanges of foot) to describe the diagnosis
• E007.0 (Activities involving American tackle football) to represent the cause of the injury.

Example 2: A 16-year-old male new patient reports to the orthopedist with an injured left toe, which happened during a tackle football game. The physician documents a level-two E/M with an X-ray and pain meds. After reviewing the X-ray the physician diagnoses a proximal phalanx fracture on the foot, which he wraps in a splint. The encounter notes read "non-displaced fracture splinted in good position. Treatment with NSAIDS for pain."

This is an example of non-manipulative care. On the claim, report the following:

• 99202-57 for the E/M
• 28510 (... without manipulation, each) for the fracture care
• 826.0 to represent the diagnosis
• E007.0 for the cause of the injury.

Profit Difference: CPT 28515 pays about $144.17 (3.91RVUs multiplied by 36.8729 conversion factor), while 28510 earns you about $109.88 (2.98 RVUs).