Orthopedic Coding Alert

When patients go on skiing vacations and return with new injuries, both the treating and post-op physicians can collect

Whether you're in Florida or Colorado, chances are you're going to have to code for ski injuries this season - and it doesn't have to be an uphill battle. Use this expert strategy for coding your physician's subsequent care of patients who tackled the mountain and lost.

Split Care Warrants Modifier -55

Coders in warmer clients are often unfamiliar with reporting skiing injuries ... until a patient goes on vacation and returns in a cast. If you take over the fracture care, you can still recoup reimbursement for your physician's services if you append modifier -55 (Postoperative management only).

Suppose a patient falls while skiing in Colorado. The local orthopedic surgeon sees the patient in the emergency department and diagnoses a closed femoral shaft fracture (821.01, E885.3). He treats the fracture with intramedullary rodding. The patient returns to her home in Florida, where a local orthopedist takes over her follow-up care. The Colorado orthopedic surgeon reports the surgery code (27506, Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws), so where does that leave the home-town orthopedist?
 
The physician in Colorado performed the surgery, so he should report the surgical CPT code with modifier -54 appended, says Mary Ellen Fletcher, CPC, administrative assistant in the reimbursement department at the American College of Emergency Physicians. Modifier -54 (Surgical care only) tells the payer that the Colorado physician performed the surgery only, not the postprocedure care. The Florida physician would report 27506-55 to denote his work performing the postprocedure care during the global period.
 
Scrutinize Op Report for Boot-Top Fracture

Boot-top fractures are common skiing injuries, but some coders aren't sure how to report this diagnosis. "A boot-top fracture is any tibia fracture, with or without fibula fracture, that occurs at the top of a ski boot," says Paul K. Kosmatka, MD, orthopedic surgeon at the Marshfield Clinic. You would assign 823.xx (Fracture of tibia and fibula ...) to this injury.
 
"Usual treatment is surgical, either with an intramedullary rod or plate and screws," Kosmatka says. "Occasionally, a nondisplaced boot-top tibia fracture can be treated in a cast."
 
If the surgeon inserts an intramedullary implant, you should report 27759 (Treatment of tibial shaft fracture [with or without fibular fracture] by intramedullary implant, with or without interlocking screws and/or cerclage).
 
If the orthopedist performs a closed tibial shaft repair with manipulation, 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction) is the right code.
 
If the orthopedist subsequently removes the hardware (such as screws and plates), you should bill 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]). Report only one unit of 20680 if the surgeon removes all the hardware through the same incision.
 
If the operative report shows that the orthopedist removed additional pieces of hardware through separate incisions, you can report additional units of 20680 with modifier -59 (Distinct procedural service) appended.

Code Skier's Thumb as Joint Sprain

Skier's thumb (842.12, Sprains and strains of wrist and hand; metacarpophalangeal [joint]) accounts for about 10 percent of all skiing accidents, and although it may sound minor, coding for thumb surgeries can be
quite complex.
 
When a patient first presents with a thumb injury, the orthopedist will test the laxity of the ulnar collateral ligament, check whether the three major hand nerves function normally, assess the hand for fracture, and determine whether the patient has any injuries to the hand or wrist. You should report an E/M code (99201-99215 for outpatients) for this examination, along with an x-ray code (73120-73140) if the orthopedist performs one.
 
If the physician applies an ACE bandage or other strapping material to immobilize the thumb, you should report 29280 (Strapping; hand or finger) along with the E/M code. Because the National Correct Coding Initiative does not bundle the strapping and E/M codes, you shouldn't have to append any modifiers to recoup strapping reimbursement.
 
If you treat the injury with a thumb spica cast, you should report 29075 (Application, cast; elbow to finger [short arm]).
 
While many of these injuries can be successfully treated nonoperatively, if the torn ligament is displaced, nonoperative treatment will fail and surgical repair may be necessary. 
 
The most common code for these repairs is 26540 (Repair of collateral ligament, metacarpophalangeal or interphalangeal joint).