Pediatric Coding Alert

Treating a child with a possible fracture can require a lot of time. The pediatrician may not immediately know if a fracture is present, and may expend almost the same time and effort whether it exists or not. The fracture repair codes -- which pay very well -- apply only if there is a fracture. If no fracture exists, payment may be less, but you can still maximize reimbursement with careful coding of the documented services.

 

 

A 10-year-old slips while playing with friends, twisting an ankle. The ankle is very swollen when the child is seen that afternoon. The pediatrician conducts an evaluation to be sure there are no other injuries and sends the patient for an x-ray.

The radiologist calls to report that the x-ray is negative, and the patient returns to the office. The pediatrician prescribes ice packs and Tylenol, and tells the patient to return as needed. In this case, bill for an E/M visit (99212-99215, established patient) and any subsequent visits. Use diagnosis 845.00 (sprains and strains of ankle and foot; ankle; unspecified site).

Pediatricians without x-ray equipment in the office would probably talk to the parent on the phone after the radiologist reads the x-rays. Because you cannot use phone time to upcode the level of office visit (it is not face-to-face), you should provide most of the education for care in your office before sending the child to the radiology office (i.e., tell the parent how to care for the injured ankle while he or she is still in your office, prior to the x-ray). Such counseling time, if more than 50 percent of the total encounter time, can be used to upcode the E/M level. If the x-ray is positive, you will likely (but not necessarily) refer the child to an orthopedist.

Bill the fracture repair codes when treating a fracture. For example, a 7-year-old child presents with what you suspect may be a distal radial fracture sustained during a volleyball game. You examine the arm, determine if there are any other injuries and send the patient for an x-ray. 

The radiologist calls, stating that there is a buckle fracture. When the patient returns to your office, treatment consists of casting -- for which you bill 25600 (closed treatment of distal radial fracture) -- and recommending ibuprofen. Use diagnosis code 813.42 (fracture of radius and ulna; lower end, closed; other fractures of distal end of radius [alone]).

In addition to the fracture repair code, you may bill an E/M service because you provided a significant, separately identifiable service in addition to the fracture repair. Although you saw the child twice -- before and after the x-ray -- report only one E/M code, taking into account the total amount of work done for both visits. For example, if the first encounter (when you evaluated the wrist but didn't know whether it was broken) would have qualified for a 99212, add the work of treating the fracture and report 99213. Append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. 

If a patient's broken bone is serious enough to warrant a referral to an orthopedist, the pediatrician should still bill an E/M service for his or her visit.

 

 

Sometimes, whether or not the bone is fractured, the pediatrician applies a splint.

 

In a common pediatric scenario, you may know the orthopedist should see the child, but it's not an emergency. For instance, the child falls from a swing and has a nondisplaced fracture of the radius. You send the patient for an x-ray and discover the fracture. You call the orthopedist, who says he will see the child the next day. In the meantime, because the arm is fractured, you apply a splint. Report 29125 (application of short arm splint [forearm to hand]; static) for this service. 

 

Note that you cannot use the casts or strapping codes (29000-29590) if you also bill the fracture repair code. Likewise, you cannot use the casts or strapping codes if you provide the subsequent injury care. Only use these codes if you are applying the splint as a temporary procedure to stabilize or protect, or to afford comfort, while the patient waits to see the orthopedist.

 

 

In general, there are two ways to code a nondisplaced closed repair, says Laura Neuchterlein, senior policy analyst with the American Academy of Orthopedic Surgeons. You can bill a fracture repair, or you can bill an E/M service. If you choose to bill the E/M service instead of fracture repair, you can charge the casting and splinting code as well as, and -- because there is no global period -- all subsequent E/M services.

 

 

Although fracture repair codes pay well, they include 90-day global periods, and therefore you cannot bill for follow-up care unless there is a complication, such as an infection of a wound that is related to the fracture or circulation problems that require removal and reapplication of a cast.

 

If you see the patient for any purpose during the 90-day period following the billing of a fracture repair code, you must use modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period). In pediatrics, where patients develop frequent viruses, ear infections, fevers and so on, you will likely need to use modifier -24 during the post-operative period of a fracture repair.

 

You can bill for casting material using supply codes in HCPCS during the global period, Neuchterlein says. For example, if you want to examine the injured area and need to remove and replace the cast, code for the casting material during the 90-day period. By the same token, you can bill for casting material on the same date of the injury if you must apply a cast for stabilization and pain control with restorative treatment by another physician.