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 care, we found a few excerpts from other state Medicare sites to support Callaway-Stradleys contention and that of Stilleys physicians that the orthopedic surgeon can bill for full fracture care.

Palmetto Government Benefits Administrators, the Medicare Part B carrier for South Carolina, does not list the specific issue of the patient leaving the ED and going to the orthopedists office later. But it does imply that both the ED and the orthopedist have billable services:

Emergency department physicians generally do not assume care for restorative treatment of orthopedic procedures performed in the ED. Often an ED physician will perform services to evaluate and ameliorate the specific situation and refer the patient to another physician for definitive care.

After completing the services rendered to the ED patient the ED physician should consider two questions when billing for ED services:

1. Will any restorative treatment or procedure(s) (e.g., surgical repair, closed or open reduction of a fracture or joint dislocation) be performed [by the ED physician] or are they expected to be performed?
2. Will the same [ED] physician assume all subsequent fracture, dislocation, or injury care?
These two issues can provide an excellent guide for final coding determinations.

For example, an ED physician determines that a patient has a fracture of an extremity and applies a cast. The ED physician instructs the patient to follow up with another physician. The ED physician would answer no to the above questions. Therefore, the ED physician would bill for the appropriate casting code 29000-29590 and if the key components of are met, an evaluation and management (E/M) service with the -25 modifier.

Under the Palmetto policy, the orthopedic physician also could bill for the fracture care, using the appropriate codes 29000-29590. And if the key components for the evaluation and management (E/M) codes are met, then the appropriate E/M level can be reported, along with either modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (decision for surgery).

Wisconsin Physician Services Inc. is the Medicare Part B carrier for Wisconsin, Illinois and Michigan. Its provider manual gives an example specific to Stilleys question:

(For ED care,) additional services should be listed as performed. For example, this would include suturing lacerations or applying a cast.

Note: When the service has a global period, all services typically performed during that time must be provided by the billing physician. When a patient presents to the ER with a fracture, typically the ER physician diagnoses and stabilizes the fracture, and refers the care to another physician (e.g., orthopedic specialist). The ER physician in this situation has not provided fracture care. Therefore, he or she would bill for the ER services, and the specialist would bill the fracture care.

When Is it Not OK?

Callaway-Stradley reminds that billing fracture care would not be appropriate if the treatment was a closed, non-manipulated fracture that actually was set by the ED physician. If the treatment rendered by the ED physician is considered definitive, and the patient goes to the orthopedist days or weeks later to be followed-up for that same treatment, the orthopedist should not bill for fracture care. The options are to bill the fracture care code with a -55 modifier (postoperative management only) or bill the individual office visits as they occur, making sure to indicate by diagnosis code that postoperative services are being rendered. But if the patient doesnt show up in the orthopedists office until days later, and if the splint is used to stabilize until more definitive care can be rendered (e.g., the next day or after the weekend), then the orthopedists billing for fracture care is correct, Callaway-Stradley adds.