Pediatric Coding Alert

Know when to code buddy tape separately.

Kids are great at having fun, but they’re also great at accidentally getting hurt. Not everyone wants to take their child to the emergency room after a fall. Pediatric clinics therefore treat their fair share of fractures.

Fracture care isn’t always complex, especially in a pediatric clinic setting. Follow this case study to help you brush up on your simple fracture care coding.

The Case: A parent brought their 10-year-old to the pediatric clinic. The established patient was walking outside at home and slipped on some ice. She is now complaining of severe pain in her left foot, specifically in the area of her small toe. The girl has no known allergies and no significant past medical history.

Upon physical examination, the pediatrician noted swelling and tenderness over the left small toe. The girl was unable to move her toe without experiencing pain. The pediatrician suspected a possible fracture and ordered an X-ray, which confirmed a small fracture that did not need manipulation. The pediatrician then applied a buddy tape to the fractured toe and the adjacent toe to immobilize it and prescribed over-the-counter pain medication. The girl was advised to rest and avoid putting weight on the foot as much as possible. The pediatrician scheduled a follow-up appointment in one week to monitor the healing process.

Navigate the Toe Fracture Treatment Codes

If you’re unfamiliar with these codes, using them can seem a bit overwhelming. You’ll likely first come across the following when looking for the one that best matches the treatment in the case study.

• 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation)
• 28495 (… with manipulation)
• 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each)
• 28515 (… with manipulation, each)

If you look at the descriptors carefully, you’ll see several things that the codes have in common. The first is that they all describe closed treatments of the fracture. This means the fracture is treated without any surgical incision. This generally means realigning the bone through manipulation or some kind of split.

Note: You’ll also come across codes that describe “open” treatment, which refer to the fracture site itself being open to the external environment, not that the physician opened the site. This type of injury is rare even in an emergency room setting and is most likely too severe an injury for a parent to bring to a private practice or clinic.

Fracture care codes are also subdivided into “manipulation” or “without manipulation,” notes Samuel “Le” Church, MD, MPH, CPC, CRC, FAAFP, core faculty family medicine residency at Northeast Georgia Health System. Fracture manipulation (or fracture reduction) is a procedure that’s used to align broken bones that are angulated, displaced, or dislocated to promote proper healing. The physician uses their hands or specific tools to adjust the pieces of the fracture into their normal position.

However, in the case study, the pediatrician did not manipulate the bones. So, which code should you report?

Don’t Jump to Fracture Care Codes if an E/M Code Will Do

If you look too quickly to a fracture care code such as 28510, you’re likely also looking at a denial. Because the pediatrician did not manipulate the bone or provide any additional care specific to the fracture outside of the buddy taping, the only treatment code you need to report is 29550 (Strapping; toes). Buddy taping, otherwise known as toe strapping, describes the process of taping the injured toe to the adjacent toe for support and to limit movement, which helps promote healing.

Coding alert: In cases where the injury is severe enough to require manipulation and significant care in addition to the strapping, you would not report 29550, as it is bundled with the initial fracture care code.

Parse Out Important Details for ICD-10 Coding

Now that you understand which service codes to provide, consider the details of the notes. There is a lot of information to go through, but the first thing to do is determine everything that’s important for proper coding.

You’re dealing with an injury, which means you’ll report an S code. These codes provide information about the cause, location, and type of injury. Therefore, for coding this encounter, the following information would be needed:

• The location of the injury (left small toe)
• The type of injury (fracture)
• The treatment provided (buddy taping and pain medication)
• The cause of injury (fall on ice)

Specifically, you’re looking at S92- (Fracture of foot and toe, except ankle). You’ll see that these codes also require a seventh character. Therefore, in order to report the correct diagnosis code, you’ll need to also know that this is an initial encounter for this injury because the patient is receiving active treatment. When you follow S92 to include all the information above, you come to S92.355A (Nondisplaced fracture of fifth metatarsal bone, left foot, initial encounter for closed fracture).

Remember External Cause Codes

While no national requirement exists, some states or payers may require you report external cause codes, Even when they don’t, reporting codes appropriately from Chapter 20 [External Causes of Morbidity] “…provide valuable data for injury research and evaluation of injury prevention strategies,” according to the ICD-10 guidelines.

In this case, the patient fell on the ice, which brings you to W00 (Fall due to ice and snow). It’s important to note that

these codes also require the appropriate seventh character. You’ll add an “X” for any digits necessary to reach 7 characters. You don’t know details of the fall, so you will need to default to unspecified code W00.9XXA (Unspecified fall due to ice and snow, initial encounter).

Coding alert: “There are important guidelines to follow for assigning external cause ICD-10 codes,” explains Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Physician’s Computer Company in Winooski, Vermont. “One thing to remember is they may never be a principal diagnosis and may even be unnecessary if the cause and intent are included in the condition code itself, such as with T39.011 (Poisoning by aspirin, accidental (unintentional)),” she continues.

Also, there is a hierarchy to observe when reporting multiple external cause codes. For example, Guideline Section I.C.20.f begins: “External codes for child and adult abuse take priority over all other external cause codes.” “These precede any other external cause codes including those for terrorism, cataclysmic events, transport accidents, and others,” says Blanchard.