Orthopedic Coding Alert

Orthopedic coders sometimes use E codes (external causes of injury and poisoning) to enhance reimbursement for claims for fractures and other injuries. But commercial carriers often deny claims when E codes are used to supplement other diagnostic codes. The key to optimizing reimbursement with E codes after determining which carriers accept them is to use them correctly with the diagnosis code, to followup with the patient, and to clarify the documentation of the accident.

In the orthopedic setting, E codes are used when the patient has an injury or accident that is the result of environmental events or circumstances. They range from the common (E880.9, fall from other stairs or step) to the obscure (E847, accidents involving cable cars not running on rails) and describe virtually every accident in which an external factor was involved. In claims for injuries, E codes help answer the question, How did it happen? They inform the carrier with a short description of how an accident occurred.

Two Codes Are Usually Required

Using E codes to describe how an injury occurred is usually a two-part process. One code describes what the patient did he or she fell, got hit by a car, etc. A second code describes where the accident occurred in the patients home, at an amusement park, airport, bank, etc. These place of occurrence codes are in the E849 series, with a fourth digit required to specify location. Especially important for workers compensation claims, they help the carrier determine both circumstances and liability for an injury. Most workers compensation carriers insist on the use of E codes to explain how the injury occurred, the intent (whether accidental or intentional) and the place of incidence.

Likewise, E codes do not replace diagnostic codes; they simply better explain the circumstances of an injury, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. If a patient falls off their front porch and breaks their arm, there are three codes that apply, she says. Code 813.42 (other fractures of distal end of radius [alone]) describes the injury, and E882 (fall from or out of building or other structure) tells the carrier that the patient fell off a porch. The third code, E849.0 (place of occurrence; home), informs the carrier where the accident occurred. The three codes together describe the what, where and how of the accident, Callaway says.

E codes do not have a reimbursement factor; in other words, they will not impact the amount a practice is paid for treating an injury. They are the last code reported in a claim and are for information only. The codes are never to be reported in lieu of a [...]