Orthopedic Coding Alert

There are a variety of treatment options for pediatric femoral shaft fractures, and the patient presenting at the emergency department (ED) further complicates the coding process. Coders must give a complete picture of the situation and the specific services and treatment provided by the orthopedist. The following examples illustrate the complexities involved.

A parent brings a 10-month-old infant to the ED at 11:00 on a Saturday evening. The child is extremely irritable and obviously agitated, and his presentation indicates he is in pain. Earlier on the same day, at 11:00 a.m., a 12-year-old girl was brought to the ED by ambulance. She had fallen off a horse. Her verbal complaints and visible injuries to her right thigh indicated a comminuted femoral fracture. An orthopedic surgeon was called immediately.

Both children will be diagnosed with fractures of the femoral shaft. But beyond that, the cases differ and so does the coding.

Diagnosing and Treating the Infant

The Intervention: The ED physician examines the infant and discovers abdominal trauma and a swollen left thigh with some rotation. Because a displaced femoral fracture is suspected, the ED physician orders a radiograph. Interpretation of the x-ray confirms a fracture of the shaft of the left femur.

The ED physician calls an orthopedist. The orthopedist reviews the interpretation of the x-ray and immediately takes over the care of the infantwhich ultimately results in the orthopedist admitting the patient to the hospital.

When the orthopedist meets with the father of the infant to review treatment plans, the parent says he does not know how the child sustained the injury. But the distraught parent reveals that his wife left him for another man earlier in the day.

The orthopedist documents the family instability on the infants chart but gives first priority to a closed fixation of the femur. Because the abdominal trauma, which is discovered to be limited to cutaneous tissue, precludes immediate spica placement, traction is used to align the split femur until the skin heals. Two days later, a spica cast is employed.

Although the father is instructed in spica cast hygiene, the cast becomes more and more soiled. As an intermediate step at one week, the physician cuts away some of the spica material around the genitals and anus. But at two weeks, a new spica cast must be applied.

During the course of treatment and follow-up, the orthopedist begins to suspect the childs injury was caused by physical abuse. A social worker is called to consult with the father. The father ultimately acknowledges he struck the baby when it would not stop crying and he admits he fears he caused the injury.

Coding: The orthopedist did not interpret the x-ray or write the report. (The ED physician did.) Therefore, the orthopedist cannot report the corresponding CPT code for the radiograph. And although he reviewed the x-ray and the report, the orthopedist cannot report the CPT code for the radiograph with modifier -26 (professional component) because he had no reasoni.e., disagreement with the interpretation of the ED physicianthat required him to reinterpret and write a new report for the visualization of the x-ray.

Moreover, because the orthopedist takes over the care of the infant and admits the infant, the initial hospital encounter should be coded using the correct evaluation and management (E/M) code (time and complexity determined) from the series 99221-99223, initial hospital care.

Note: Consider a slightly different scenario: The ED physician makes a request of the orthopedist for a consultation. The request of the ED physician and the results and recommendation of the orthopedist are recorded in writing to the ED physician. A staff pediatrician admits the infant. The orthopedic surgeon (OS) returns the next day and takes over care of the infant. The orthopedist would bill the initial encounter with the infant as a consultation (99241-99255, code determined by setting, complexity).

Code 27502 (closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction), which the orthopedist reports, includes the application of the spica. But Blair C. Filler, MD, director of medical education at Los Angeles Orthopedic Hospital in Calif., says, This is a gray area since the spica cast was applied after traction treatment. For example, if the physician initially thought traction alone might be the treatment, a justification could be made for coding the application of the spica.

The replacement spica is reported using 29305 (application of hip spica; one leg). No modifier is needed because deterioration of the casts condition (due to poor hygiene) necessitated the replacement. If this cast is applied in the office, reminds Filler, supplies and cast materials can be charged.

The primary diagnosis code is 821.01 (shaft of femur, closed fracture), but 995.54 (child physical abuse) also must be reported.

Finally, coders give payers a complete picture of the situation by coding V61.22 (counseling for perpetrator of parent child abuse) to reflect the early intervention by the social worker the orthopedist notified, and by adding the ICD-9 E967.0 (child battering by father).

Note: Every state and the District of Columbia identify those individuals required by law to report child maltreatmenti.e., mandatory reporters. Among them are physicians, nurses and hospital personnel. The telephone numbers for the National Clearinghouse on Child Abuse and Neglect Information, U.S. Department of Health and Human Services, are 800-394-3366 nationwide, except metropolitan Washington, D.C., which is 703-385-7565. Web site: www.calib.com/nccanch.

Diagnosing and Treating the Girl

Intervention: The OS orders a radiograph, interprets it and decides to treat the fracture operatively with flexible nailing. He operates and applies a cast on Saturday afternoon.

Because he discovers the girl has not had a tetanus booster since her initial inoculation series during infancy, he gives her the appropriate injection. The girls recovery is uneventful. Twelve months later, the implants are removed.

Coding: Because the OS operated within 24 hours of first seeing the girl, all physician and patient encounters from the point of decision for surgery onward are covered within the global surgical package. But because it required an initial work-up (in the hospital visit) to make the decision for surgery, the OS can bill for seeing the patient the first time with the appropriate initial hospital E/M code (99221-99223). Modifier -57 (decision for surgery) is applied to the E/M code and exempts the consult from the global period.

The diagnostic radiograph is not part of the global package, and the OS can bill (technically) for it separately using 73550 (radiologic examination, femur, anteroposterior and lateral views). The OS also bills for the fixation with 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).

Note: Many hospitals do not permit the orthopedist to read ED x-rays because the hospital will not credential them to do so.

One year later, the same OS can bill for the removal of hardware, using 27372 (removal of foreign body, deep, thigh region or knee).

The tetanus shot is billed by reporting 90718 (tetanus and diphtheria toxoids [Td] absorbed for adult use, for intramuscular or jet injection). There are eight CPT codes for tetanus injections. The one that most closely describes the injection should be used. Adult applies to anyone more than 6 years old in the case of these injections.

If the OS makes any postoperative follow-up visit to the girl in the hospital, proper coding would include an entry of 99024 (postoperative follow-up visit, included in global service).

The primary diagnosis code for the girl is 821.11 (shaft of femur, open fracture). The ICD-9 E code is E828.2 (rider of animal, fall from animal being ridden).