Orthopedic Coding Alert

If someone is injured and needs immediate care, as in the case of a broken bone, he or she will seek the most readily available treatment, either at the emergency department (ED), a walk-in clinic, or with a primary-care physician (PCP), where he or she will have the fractured bone splinted. But the subsequent care for the fracture is often the task of the orthopedic surgeon. How then does the orthopedist bill for services regarding the fracture care?

Differing Opinions

Joanne Simmons, CPC, surgery coordinator at a four-physician pediatric orthopedic practice in Orlando, Fla., has received conflicting information as to how much her physicians can legitimately bill when they treat a fracture that has been treated first in the ED. I have checked with the AAOS (American Academy of Orthopedic Surgeons) and they feel that it is appropriate for our doctors to bill for fracture care since they consider the emergency room as a triage area, and the splinting has been applied for patient safety and comfort, says Simmons. But her billing department disputes AAOSs recommendation and says that Health Care Financing Administration (HCFA) guidelines state that the physician who applies the initial splint (in this case, the ED physician) is the one who should bill for the fracture care.

Our physicians, says Simmons, claim that we are never the one to apply the first cast or splint since most people dont come to the specialist first. They either go to an ED or to their PCP.

Old Rules vs. New Rules

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., relates that Simmons conflicting information is a result of new rules for splint placement introduced by CPT 1996. The old CPT rules (pre-1996) did not allow for separate payment to the ED physician for splint placement, so they would bill for fracture care, says Callaway-Stradley. Consequently, no other physician could bill for fracture care. But this changed in 1996. The rules about splints are clearly stated in CPT 1996, and Medicare concurs. She cites both CPT 2000 and the Medicare Carriers Manual: Restorative treatment and/or procedures rendered by another physician following the application of the initial cast/splint/strapping may be reported with a treatment of fracture and/or dislocation code.

Callaway-Stradley recommends that coders contact their local Medicare carrier or check the carriers Web site for information on local policy. She says that the above policy is fairly standard operating procedure since the CPT rules changed, so coders shouldnt find too much variance at their state sites.

State-specific Examples

Floridas Medicare site did not readily offer information on Stilleys specific problem. But in addition to HCFA and CPT clearly spelling out the rules for fracture [...]