Orthopedic Coding Alert

Also, keep several modifiers handy to separate services.

When a patient reports with an ulnar/radial shaft fracture, coders need to decide several key components of the encounter before choosing the correct code.

These include whether the treatment was open or closed, as well as whether the provider used manipulation during the surgery. There are also modifiers and additional services to consider for these fracture fix scenarios.

Read on for more information on coding radial/ulnar shaft fractures.

Know if Fracture Is Open/Closed

The first order of business on a radial/ulnar shaft fracture is open or closed. This choice will depend on whether or not the bone has come through the skin.

“An open fracture is when the bone has punctured through the skin or there is a significant break in the skin directly over the fracture site — not an abrasion or superficial laceration,” explains Jeff Weintraub, MD, MBA, FAAEM, practicing physician and business manager at Norwalk Hospital in Norwalk, Connecticut. “There is significant risk of infection and open fracture treatment usually requires some type of fixation device.”

Coders must also decide if the physician performed manipulation before choosing a code. According to Weintraub, “fractures that require manipulation are those that are angulated, displaced, or dislocated.”

Know Ulnar/Radial Fx Codes

When coding for radial/ulnar shaft fractures, you must choose from a specific set of codes. Most of those codes are contained in the following code grouping:

• 25500 (Closed treatment of radial shaft fracture; without manipulation)
• 25505 (… with manipulation)
• 25515 (Open treatment of radial shaft fracture, includes internal fixation, when performed)
• 25520 (Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation))
• 25525 (Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed)
• 25526 (Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex)
• 25530 (Closed treatment of ulnar shaft fracture; without manipulation)
• 25535 (… with manipulation)
• 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed)
• 25560 (Closed treatment of radial and ulnar shaft fractures; without manipulation)
• 25565 (… with manipulation)
• 25574 (Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna)
• 25575 (… of radius AND ulna)

Note: As you can see, some of the codes represent more than just a radial or ulnar shaft fracture — such as 25526 — but a radial or ulnar shaft fracture is the primary procedure in the code descriptor. Choose from these codes as appropriate and as dictated by the notes.

There are other codes in this set, including those for distal radial fractures and ulnar styloid fractures. However, this article does not address coding for these fracture repairs.

Know if Separately Reportable Services Occurred

There are several separately reportable services that could accompany a radial/ ulnar shaft fracture repair. There will almost certainly be a separate evaluation and management (E/M) service preceding the fix. This is often an office/outpatient E/M — think 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) — but the E/M could also occur at a hospital, especially if the fracture is open.

For hospital E/Ms, code to the notes. Your physician might provide an emergency department (ED) E/M, which you’d code with the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) set. It might also be another hospital code from 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) through 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.).

X-rays are a near-certainty in this scenario as well. The surgeon will need to confirm specifics of the fracture before proceeding with surgery, so some type of imaging will occur. Code X-rays for radial/ulnar shaft fractures with 73090 (Radiologic examination; forearm, 2 views) in nearly every scenario.

If the surgeon uses further imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), report one of the following codes:

• 73200 (Computed tomography, upper extremity; without contrast material)
• 73201 (… with contrast material(s))
• 73202 (… without contrast material, followed by contrast material(s) and further sections)
• 73221 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s))
• 73222 (… with contrast material(s))
• 73223 (… without contrast material(s), followed by contrast material(s) and further sequences)

There might also be debridement during the radial/ulnar repair. “With an open fracture the use of open fracture debridement codes may be necessary, in addition to the fracture reduction code,” says Denise Paige, CPC, COSC, coder with PIH Health Physicians in Whittier, California. Report debridements during these fixes primarily with the following codes:

• 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues)
• 11011 (… skin, subcutaneous tissue, muscle fascia, and muscle)
• 11012 (… skin, subcutaneous tissue, muscle fascia, muscle, and bone).

Fixation Device Is a Possibility

In the case of an open fracture, the surgeon may place an external fixator, which you would most often report with 20690 (Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system). Codes for open treatment include use of internal fixation.

Know Which Modifiers You Might Use

There could also be several modifiers at play in your radial/ ulnar fracture repair coding scenario. If there is an E/M service before the fracture repair, append modifier 57 (Decision for surgery) to the E/M to show that the surgeon made the decision to operate during this E/M. Use modifier 57 on any of the separate presurgical E/Ms your surgeon might perform — be they office/outpatient or hospital/inpatient.

No 25? Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) would accomplish the same task as 57 for these separate presurgical E/Ms — if the global days were different on the surgeries.

All of the radial/ulnar fix codes addressed in this article have a 90-day global period (major), meaning you’ll append modifier 57 to any presurgical E/M. If the presurgical E/M had a 0- or 10-day global (minor), then you’d opt for modifier 25.

Also, you’ll want to include modifier LT (Left side) or RT (Right side) on the fracture care code to indicate laterality.

Modifier 51 (Multiple procedures) might also come into play, especially on open fractures that involve debridement or fixation. For debridements or fixations that aren’t bundled into the fracture care code, append modifier 51 to show that they are separate services from the fracture fix.