Orthopedic Coding Alert

Question: How should we report rib fracture repairs?

New York Subscriber

Answer: For so few words, that’s a pretty big question. The short answer is that it depends on the type of treatment the orthopedist employs to fix the breaks.

For open treatment of rib fractures, you’ll choose from one of the following codes:

• 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs)
• 21812 (… 4-6 ribs)
• 21813 (… 7 or more ribs).

Open treatment definition: According to Codify, in open treatment “the provider treats broken ribs, usually the result of trauma, through an open surgical approach. The provider may treat one to three ribs with internal fixation techniques, and he may perform a thoracoscopy for better visualization of the procedure.”

If the orthopedist performed closed treatment of rib fractures, use the appropriate evaluation and management (E/M) code for the entire encounter. During a closed rib fracture treatment the orthopedist sets the fracture using manipulation.

So, if the orthopedist performs a closed fracture on a patient’s ribs in the office, you’d roll the work for the rib repair into the overall E/M level and choose a code from the 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) code set.