Orthopedic Coding Alert

Proper coding for post-emergency fracture care presents an array of reimbursement challenges for orthopedic practices. The results largely depend on the services performed and coding used in the referring emergency department (ED). You can have incredibly varied types of situations depending on the physicians available and the types of arrangements made, advises Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, SC.

Some ED physicians, for instance, rarely do any fracture care. In the case of a simple fracture, they prefer to stabilize the injury and refer the patient to an orthopedist for setting and follow-up care. Others take a do-it-yourself approach and repair all but the most complicated breaks, referring patients to orthopedists only for follow-up care, she explains.

Along with differing levels of intervention, ED physicians also take different approaches to fracture care billing.

1. Global Fracture Billing: Some practices erroneously bill under global fracture care codes, which include the fracture repair, casting and all follow-up care for 90 days. A practice using a global fracture care code needs to follow up for the extended period, so its probably not appropriate for the ED to bill that way, says Annette Grady, CPC, CPCH, coding and reimbursement coordinator for the Bone and Joint Center, an eight-physician orthopedic practice in Bismarck, ND.

The good news for orthopedic practices is that, in instances when both the ED and orthopedist submit claims for the same global fracture care, the ED department will likely come up short, according to Callaway-Stradley. If the ED bills under global care without using a -54 modifier to indicate performance of the surgical procedure only, then ultimately theyll have to pay for it, she says.

Good communication with referring EDs is probably the best way to avoid such errors and simplify orthopedic coding, but that kind of coordination is rarely possible.

Absence of ongoing dialogue and not otherwise knowing how the referring ED physician will bill for its services should not hinder orthopedic practices billing. Never be afraid to bill as long as you know your coding and documentation is correct, Callaway-Stradley advises.

2. ED Sets Fracture: If the ED doctor sets a non-displaced arm fracture (818.x), the ED should properly bill for an E/M code (99281-99288) and cast application (29049-29085), according to Grady. Coding for follow-up care by the orthopedist should generally fall under global fracture care. However, it varies depending on how quickly the patient arrives in the orthopedic office after the ED treatment and the extent of expected follow-up. At the Bone and Joint Center, for example, if a physician expects a lengthy follow-up, the practice will charge for global fracture care; if not, it will bill for an E/M with a cast application, Grady explains.

3. Extended Time Before Follow-up: If a patient treated in the ED for a simple fracture takes a week or more to come to the orthopedic office for follow-up, its probably too late to charge for global fracture care, Callaway-Stradley advises. The healings well on its way by then, and you should never bill for total fracture care; just follow up with the most appropriate care codes. Either use a global fracture code with a -55 modifier to indicate that only postoperative care was rendered, or an E/M code and cast application, she says.

4. Incorrectly Set Fracture in ED: When the ED physician sets a displaced fracture, it should charge for global fracture care with manipulation, i.e., use the -54 modifier to indicate performance of a surgical procedure only. The orthopedist who sees the patient in follow-up would then bill for his or her services as global fracture care with the -55 modifier to indicate postoperative care only. If the orthopedist discovers that the fracture was not properly set, the claim would then bill under global fracture care with manipulation. Although the same procedure initially done by the ED may be reported, theres no need for a modifier, according to Grady. The ED physician has nothing to do with the orthopedic practice, so you just code the procedure with no modifier, she explains.

5. Follow-up for Orthopod in the ED: It is appropriate to use the -77 modifier (repeat procedure by another physician) if a physician in the same practice does the same procedure. For example, if one orthopedist does an after-hours manipulation in the ED and refers the patient to the practice for next-day follow-up. His colleague who subsequently sees the patient and discovers that the fracture has not been set properly would code his resetting with the same procedure code using the -77 modifier.