Orthopedic Coding Alert

Most of your orthopedic coding cases begin and end with your own physicians, but sometimes exceptions apply. Decide how you would code the orthopedist's role in this case involving an American survivor of the Haitian earthquake. Then, check our experts' advice.

The scenario: The patient suffered a compound fracture to the left tibial shaft. A Navy physician stabilized it on the transport ship and applied an external fixator. When the patient arrived at a U.S. hospital, the plastic surgeon on duty was called in to complete skin and muscle grafts. He discovered a gap between the bones in the patient's leg and thought she would need a bone graft. He called in an orthopedist who was already in the OR and had him take a look. The orthopedist consulted with the patient about needing to perform a bone graft and reset the bone. The orthopedist debrided the site and used cadaver bone to complete the graft. He placed internal fixation and reapplied external fixation (the plastic surgeon handled the grafting and closures).

The patient stayed in the hospital several days,then went to a local rehabilitation facility. She saw the orthopedist for follow-up care. The orthopedist later removed the fixator and continued monitoring her progress until she healed and returned home.

The orthopedist completed several steps during the surgery,ranging from an inpatient consultation to the bone grafting.

Consult: Report 99253 (Inpatient consultation for a new or established patient ...) for the initial consultation in the Emergency Room. Append modifier 57 (Decision for surgery).

Fixate: Choose 27758 (Open treatment of tibial shaft fracture [with or without fibular fracture], with plate/ screws, with or without cerclage) for the new fixator. "It's not uncommon to do both internal and external fixation of these fractures," says Ruby O-Brochta-Woodward, BSN, ACS-OR, compliance and research specialist with Twin Cities Orthopedics in St. Louis Park, Minn. "External fixation holds the fracture out to length and provides stabilization so the fracture ends are not moving around. The internal fixation would provide more stability to the graft and added compression to the fracture."

If the surgeon had not placed internal fixation, you would append modifier 52 (Reduced services) to 27758.

Clean: Select 1101x (Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s] ...) for wound cleaning. Include modifier 59 (Distinct procedural service) to report the debridement in addition to the fixator application.

Graft: "From the physician's side of billing, we can only bill for autograft, if grafting is not included in the CPT description," says Jacqui Jones, office manager for an orthopedic physician practice in Klamath Falls, Ore. Because this case involves an allograft, you could only report the graft if "There was documented, substantial difficulty with the allograft," Jones says.

When the patient sees your orthopedist for follow-up care, those visits are part of the surgical global period so won't be coded separately. You might be able to code for the external fixator's removal, however, depending on the circumstances.

"Subsequent removal of the external fixator would be billable only if this was done in the operating room under anesthesia," explains O'Brochta-Woodward. "If the physician performed this in his office it would not be separately reportable even though he did not place the fixator."

Code choice: If the patient returns to surgery for the fixator's removal, report 20694 (Removal, under anesthesia, of external fixation system). Internal fixation can be removed, but usually is left in situ, says Bill Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C. If the internal fixation is removed, the surgeon typically does not complete it until about six months after the initial procedure.