Pediatric Coding Alert

Just because another group beats you to the punch in filing a fracture care claim doesn't mean you have to forfeit pay, provided you're savvy at breaking up the package -- and getting the other entity to do the same.

Test your fracture care coding aptitude with these scenarios.

Example 1: A pediatrician treats a clavicle fracture by putting the child's arm in a sling and sees the child for follow-up (FU). Which CPT code should you use?

When a physician treats a fracture and provides the after-care, you should report the global fracture care code (such as 23500, Closed treatment of clavicular fracture; without manipulation), says Charles Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in southern New Jersey. These pay for the restorative care, first cast/splint and FU care visits for a designated period, such as 90 days.

Example 2: A hospital emergency department's (ED's) manipulative fracture care policy calls for the ED physician to assess/evaluate an injury, have an orthopod treat the fracture and the primary care physician provide all FU care. How should the physicians code their roles?

The ED physician, orthopod and pediatrician should divide the care. Piecemeal the aftercare visits with the pediatrician using E/M codes, Scott says.

The orthopod would code the manipulative fracture care with modifier 54 (Surgical care only) for the procedure care only, Scott says. Only the physician who provides the restorative treatment and is responsible for the initial cast, follow-up evaluation(s) and the management of the fracture until healed should use the global code.

The ED physician should report an ED visit (99281-99285) for the injury assessment/evaluation and any temporary casting for stabilization. "If cast application or strapping is provided as an initial service (e.g., casting of a sprained ankle or knee) in which no other procedure or treatment (e.g., surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code (99070) in addition to an evaluation and management code as appropriate," states CPT's casts and straps application notes.

The pediatrician would then report the individual office visits, as well as any other x-rays, procedures, or casting that he may perform. Or, the pediatrician could bill the fracture care with the postoperative portion by using modifier 55 (Postoperative management only).

Example 3: An ED physician bills the global fracture care code and sends the patient with a report to her pediatrician with a request for follow-up care. Should the pediatrician use a consultation code?

Error averted: The pediatric office should not bill a consultation code (99241-99245) because the ED physician is not requesting an opinion from the pediatric office, but transferring care, says Lynn M. Anderanin, CPC, CPC-I, senior coding consultant for Health Info Services in Park Ridge, Ill.

When the fracture care involves manipulation, the ED should bill the correct code for fracture care with modifier 54, Anderanin continues. Catch: For fracture care without manipulation, the ED should bill for the application of splints/casts, but not fracture care.

To avoid double-dipping on manipulative fracture care's postoperative care portion, you might need to go to the hospital's medical director with this information. "Since emergency physicians usually provide only the initial management for F/D conditions and not the follow-up care, the 54 modifier needs to be appended to the appropriate F/D code to communicate that the physician provided initial care only," according to the American Academy of Emergency Physicians "Orthopedic FAQs" (http://www.acep.org/PrintFriendly.aspx?id=30488).

The pediatric office should bill the same fracture care code with modifier 55, Anderanin says. "Some carriers require the date of the fracture care in box 19 on the post-operative care billing."

Alternatively, the pediatrician could bill established office codes, plus x-rays and additional casting/splinting and supplies that he provides.

Example 4: You evaluate an injury as potentially being a fracture and send out the film. You recommend a wait-and-see approach, advising the teenager if the injury worsens or doesn't improve in 3-5 days to return to your office. Days later the film comes back positive. The patient returns for you to treat the fracture. How would you code these services?

Action: Piecemeal this fracture care that occurs on separate dates of service, Scott advises. You would code the assessment, the treatment and follow-up with individual E/M codes.

Or bill the E/M at the initial visit. And then for the remainder use the fracture care.