Orthopedic Coding Alert

Orthopedists on call to their local emergency department (ED) are often required to treat serious trauma due to automobile or other types of accidents. In cases of multitrauma, where several bones may be crushed, fractured or dislocated, injuries are likely to be treated operatively and nonoperatively. Relative value units (RVUs) can help the coder list multiple CPT codes in a manner that is both correct and obtains the highest reimbursement.
 
Although the same coding rules apply for trauma cases as for any other orthopedic services, multiple injuries increase the likelihood of coding challenges. Julie McGregor, CMA, insurance coordinator for Sports Medicine and Joint Replacement Specialists in Ft. Myers, Fla., reminds coders that extra diligence is required in cases like these. "When coding multiple trauma injuries and services," she says, "it's still essential to start with the most expensive procedure and work down" regardless of which procedure was performed first. Since payers will take reductions on subsequent procedures after the first one, the procedure with the highest RVU should be listed first because it will receive full payment.
 
She adds that matching the correct diagnosis code with the correct procedure is essential too because the surgeon's report will list a number of both CPT and ICD-9 codes, but it's up to the coder to link them. And correct use of modifiers will ensure that your surgeon is paid for all of the services he renders in caring for a patient with multiple injuries.

 
A case study provided by a reader reveals a complex series of injuries and requisite procedures covering several weeks of care.
 
A 21-year-old male who was struck by an automobile while riding his bicycle presents to the ED with a serious crush injury to the left lower extremity with massive swelling, ecchymosis, loss of sensation in the foot and tightness of all four of the compartments of the lower leg. He also complains of left elbow and shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left calcaneal fracture and left radial head fracture and clavicle fracture.
 
He is admitted by the orthopedist and undergoes immediate surgery to stabilize his fracture and treat his acute compartment syndrome. The surgery involves a closed reduction of the tibial plateau fracture with application of an external fixator. Open treatment of this fracture and the calcaneal fracture is planned for when his fasciotomy wounds have been closed.

   
The procedures performed on the day of admission include:
 

27532 -- closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction
 

27602 -- decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) 

28008 -- fasciotomy, foot and/or toe
 

20690 -- application of a uniplane (pins or wires in one plane), unilateral, external fixation system.

 
The physician can also code for hospital admission with 99222 (initial hospital care, per day, for the evaluation and  management of a patient ...). Remind your surgeons that 20950 (monitoring of interstitial fluid pressure [includes insertion of device, e.g., wick catheter technique, needle manometer technique] in detection of muscle compartment syndrome) can be reported if this service is rendered.
 
The physician also indicated the following ICD-9 codes for the day of admission:
  

928.8 -- crushing injury, multiple sites of lower limb
  

729.81 -- swelling of limb (for the swelling in the lower left leg)
  

782.0 -- disturbance of skin sensation (for numbness in the leg)
  

825.0 -- fracture of calcaneus, closed
  

823.00 -- fracture of tibia, upper end, closed
  

813.05 -- fracture, head of radius
  

810.00 -- fracture of clavicle, unspecified part
  

958.8 -- other early complications of trauma (compartmental syndrome).

 
According to Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J., most orthopedic practices already know which procedures pay higher than others. "Obviously, if the patient has a fractured wrist and a fractured hip," Brink says, "repairing the fractured hip is the more complex and work-intense procedure and will therefore pay more." But when several similar or related procedures are performed at once, or when a straightforward procedure is complicated by circumstances of the injuries (i.e., a comminuted, or crush fracture that requires more time and work) and modifiers are required, the RVU table helps with the billing sequence.
 
"The RVU table is a good support tool for reinforcing what most coders already know," Brink says. It is particularly helpful when a claim is challenged by a carrier or when the carrier attempts to change the order of the coding sequence and pay less than 100 percent for the highest-valued procedure.
 
The fee schedule can be downloaded from the CMS Web site, www.hcfa.gov/medicare/pfsmain.htm, under the heading "Physician Fee Schedule Relative Value File" - "RVU01.EXE." The fee schedule is called "pprrvu01" and is an easy-to-use table of all current CPT codes.

 
Using RVUs as the guide to sequencing, the patient's first day of care would be coded as follows:
   

27602 -- (RVU of 16.57) linked to 928.8, 729.81, 782.0 and 958.8
   

27532-51 -- (multiple procedures) (RVU of 13.99) linked to 823.00
   

28008-51 -- (RVU of 10.73) linked to 928.8, 728.81, 782.0 and 958.8
   

20692 -- application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (e.g., llizarov, Monticelli type) (RVU of 9.50) linked to 823.00
   

99222-57 -- (decision for surgery) linked to 823.00, 928.8, 813.05 and 810.00.

 
With the lowest RVU (2.98) of any of that day's codes, 99222 is listed last.

 
Modifier -51 is appended to 27532 and 28008 because these lesser-valued procedures were performed in combination by the same surgeon during the same operative session. Neither code has "separate procedure" designation nor are they normally bundled, so modifier -59 (distinct procedural service) is not needed. Modifier -51 is not appended to 20692 because this code is designated by CPT as exempt from modifier -51. Code 99222 would normally be bundled into the global surgery package, but because the decision for surgery was made at this encounter, it is eligible for separate reimbursement. Modifier -57 communicates this information to the carrier.

 
The patient remains in the hospital while his wounds heal. On the fifth postoperative day, he is returned to the operating room (OR) for planned closure of his fasciotomy wounds on the left lower leg and left foot.
 
The codes for Day 5 are as follows:
    

13160-58 (secondary closure of surgical wound or dehiscence, extensive or complicated; - staged or related procedure by the same physician during the postoperative period)
    

13160-58-59 (... -distinct procedural service).
 
In both cases, 13160 is linked to 928.8, 729.81, 782.0 and 958.8, and the RVU (18.08) is not a factor.

 
Because the same procedure is being performed twice at two different sites, the -59 modifier is needed in addition to modifier -58. Since the return to the OR was a staged procedure, the physician's original note (from Day 1) must indicate that the return was either planned or highly likely. "The -58 is used when you know you're going back in,"  McGregor says, "or at least that there's a good chance that you'll be going back in to operate on the patient." The only other time modifier -58 is to be used, per CPT stipulations, is when the second or subsequent procedure is more complex than the original or for therapeutic procedure following a diagnostic procedure.

    
By postoperative Day 12, the swelling in the patient's lower leg has subsided enough to allow for definitive treatment of his tibial plateau fracture. His left foot remains too swollen to treat the calcaneal fracture. He is returned to the operating room for removal of the external fixation and open reduction, internal fixation of the tibial plateau.     
 

Codes for Day 12 are:
   

27536-58 -- open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation
   

20694-58-51 -- removal, under anesthesia, of external fixation system.

 
With RVUs of 29.39 and 10.50, respectively, the open treatment of the fracture is obviously coded first. The ICD-9 code for Day 12 is 823.00.

 
Modifier -58 is the correct choice for this prospectively planned procedure with modifier -51 also appended to the lesser-valued procedure.

 
On postoperative Day 26, the patient is returned to the operating room for treatment of his left calcaneal fracture. Until this point, swelling had been too severe to repair the fractured heel. Code 28415 (open treatment of calcaneal fracture, with or without internal or external fixation) is billed as the only service for that day.

 
Choosing the correct modifier to append to 28415 can cause confusion. Some coders may deem modifier -79 (unrelated procedure or service by the same physician during the postoperative period) the correct choice on the basis that this surgery constitutes the initial treatment of the calcaneus fracture and it is not related to any of the previous procedures. However, this procedure was part of the initial treatment plan for this patient and, on that basis, modifier -58 is the better choice.

   
During the hospital stay, the physician also follows the patient's radial head fracture and clavicle fractures, which were treated nonoperatively. According to the AAOS, when no "procedure" is performed in conjunction with treatment of a fracture, services may be reported using either the global fracture treatment codes or the appropriate E/M code. In this case, the physician may report 24650 and 23500 for the radial head and clavicle fractures, or a code from the 99231-99233 (subsequent hospital care ...) range if the appropriate documentation is in place. Modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) will need to be appended to the E/M code so the carrier  understands that the E/M services are not related to the surgeries that have been performed.