Orthopedic Coding Alert

Warning: One documentation slip could lead to a $230 mistake.

You could be setting yourself up for audit trouble if you ignore the number of fracture fragments in a wrist report.

But that’s not all. Matching ICD-10 and CPT® 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, experts say. And assume that you are not reporting any imaging services for the surgeon.

Analyze the Op Report

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

Procedure performed: Open reduction internal fixation of multifragmented intraarticular (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.

Choose Proper Distal Radius Diagnosis

Start from the top: According to the ICD-10 index, the default code for an intraarticular distal radius fracture is S52.57- (Other intraarticular fracture of lower end of radius). The sixth character specifies 1 (right radius), 2 (left radius), or 9 (unspecified radius). Your physician needs to provide more documentation to allow you to arrive at the more specific code.

Bottom line: You need to always report to the highest specificity to make certain your claims are paid, so you should query the physician for more information.

Apply Number of Fragments to CPT® Choice

The documentation specifies an intra-articular fracture, which means the fracture line enters a joint cavity.

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.

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.

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 30.07 transitioned facility total relative value units, but 25608 has 23.66. Multiply by conversion factor 35.9335, and down coding a 25609 service to 25608 loses you roughly $230, before adjusting for geographic pricing.

Match Modifiers to Surgeon and Assistant

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.

For the assistant, you should also append modifier 80 (Assistant surgeon), meaning you’ll report 25608-80-RT.

Reason for 81: Although the surgeon documents the assistant’s help only for the fracture reduction, you should not report modifier 81 (Minimum assistant surgeon) because this conflicts with AMA guidelines.

The guidelines specify you should report modifier 81 when a surgeon plans to perform a procedure without an assistant, but during the course of the procedure, circumstances arise that require the services of an assistant surgeon for a short period of time.

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]).

Coding roundup: You should report 25608-RT, 25608-81-RT and a more specific ICD-10 code.