Orthopedic Coding Alert

Question:One of our orthopedists performed a closed treatment of a clavicular fracture without manipulation. I reported 23500, but the payer denied the claim. When I called the payer for an explanation, a representative told me that the notes didn't indicate that the provider "performed or initiated fracture care." What does this mean, and how do I code to indicate that our provider "performed or initiated fracture care"?

Rhode Island Subscriber

Answer: In order to report fracture care properly, your providers need to state that they are initiating fracture care in the notes for the initial 23500 (Closed treatment of clavicular fracture; without manipulation) claim.

When the orthopedist performs closed treatment of a clavicular fracture, it might not be clear to the payer that the provider has treated the patient at all during the initial encounter. This treatment does not include manipulation, adjustment, or surgery, so some payers might not see enough on a claim to warrant 23500 payment without a clearly worded statement about the start of fracture care.

Best bet: In the notes for the initial assessment, the provider should include words to the effect of "Initiating fracture care for clavicle fracture." This should help clear up any misunderstandings that could arise. Then, if the payer claims that you have not documented the initiation of fracture care, you can show them the initial assessment as proof that you have.

Also, even though it might appear that the provider didn't "do anything" during the 23500 encounter, that doesn't mean that she isn't initiating treatment. Remember that you report 23500 for all of the treatment; the initial visit, and the 90-day global period, during which the patient will have to return for assessments (e.g., to make sure the fracture is healing correctly and has not become displaced, or malunion/nonunion).