Orthopedic Coding Alert

Ignore the number of fracture fragments in a wrist report, and you could be setting yourself up for audit trouble.

But that's not all. Matching codes and modifiers to your surgeon's documentation means catching every clue, whether noting an assistant surgeon or keeping open fractures separate from open treatment.

Hone your skills: Try your hand at this real-life op report excerpt, and then check your answers below. Hint: Pay attention to the assistant surgeon's role to ensure accurate modifier choices, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP, president of Healthcare Consulting and Coding Education in Boardman, Ohio. And assume that you are not reporting any imaging services for the surgeon.

Pre- and postoperative diagnosis: Multifragmented intra-articular (two fragments) fracture of the distal radius, right wrist

Procedure performed: Open reduction internal fixation of multifragmented intra-articular (two fragments) fracture of the distal radius, right wrist

Description excerpt: This was a very difficult fracture with a tremendous displacement and also intra-articular components, and the operation could not be done without the assistance of my first assistant -

A traction apparatus was applied to the hand, and maneuvering was performed by me and my assistant to reduce the fracture. Once the fracture was reduced, there was a very large dorsal defect that was filled with bone allograft. The bone allograft has been reconstituted previously.

Then a Locon-T plate was used and bent to fit the fracture fragments, especially in the distal part of the fracture. The x-rays were obtained to make sure that the plate was in good position, and it was adequately shaped. Once we identified that it was, multiple screws were applied following the manufacturer's technique.

X-rays were obtained throughout to make sure that the screws were in good position and were of good length. AP and lateral x-rays show that the screws were in excellent position. One of the screws was a little long and had to be replaced. Nevertheless, the reduction of the fracture was excellent.

Start from the top: Based on this documentation, you should report 813.42 (Fracture of radius and ulna; lower end, closed; other fracture of distal end of radius [alone]) as the diagnosis, Vogelberger says.

Closed code clue: The documentation doesn't specify whether the distal radius fracture is open or closed, but the AHA's Coding Clinic advises you to report a closed fracture code, such as 813.42, if documentation doesn't indicate closed or open.

And remember that you shouldn't assume you should report an open fracture code (such as 813.5x, - lower end, open) when the surgeon performs an open reduction -- or a closed fracture for a closed reduction. Bottom line: Base your ICD-9 choice on the documented fracture rather than the procedure.

The documentation specifies an intra-articular fracture, which means the fracture line enters a joint cavity, says Bill Mallon, MD, an orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.

You have two code choices for open treatment of a distal radial intra-articular fracture:

- 25608 -- Open treatment of distal radial intraarticular fracture or epiphyseal separation; with internal fixation of 2 fragments

- 25609 -- - with internal fixation of 3 or more fragments.

Solution: Code 25608 describes this procedure, Vogelberger says.

Documentation do: For distal radial fractures, the surgeon must document the number of fragments -- as the surgeon documents two fragments in our case study -- so you may choose the proper code.

If the surgeon describes a comminuted fracture but doesn't offer a specific number of fragments, you-re still in the clear for coding. A comminuted fracture means the bone is divided into more than two fragments, which indicates you should report 25609 in that situation, Mallon says.

Watch out: You could open yourself to audit trouble if you choose 25609 without documentation of three or more fragments.

Encourage your surgeon to document numbers by showing her that 25609 has 26.16 transitioned facility total

relative value units, but 25608 has 20.5. Multiply by conversion factor 38.087, and downcoding a 25609 service to 25608 loses you roughly $216, before adjusting for geographic pricing.

Once you-ve chosen the appropriate CPT code, you need to choose the proper modifiers to help tell the patient's story.

For the surgeon, you should report 25608-RT (Right side) to indicate which side the surgeon operated on, Vogelberger says.

For the assistant, you should also append modifier 81 (Minimum assistant surgeon), meaning you-ll report 25608-81-RT, Vogelberger says.

Reason for 81: The surgeon documents the assistant's help only for the fracture reduction, Vogelberger says. If the assistant played a larger role, you could consider modifier 80 (Assistant surgeon), she adds.

Resident rule: If you-re at a hospital with residents, and no resident is available to assist, CPT offers modifier 82 (Assistant surgeon [when qualified resident surgeon not available]), Mallon says.

Coding roundup: You should report 25608-RT, 25608-81-RT and 813.42.