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.
Multitrauma Case Study  
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.
Day 1    
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, [...]