Pediatric Coding Alert

In the February issue of PCA, we covered how to code properly when a fractured finger needs to be wrapped with a splint. The answer was to use the global fracture care codes, providing that the child is not referred to an orthopedist for the care. The article stated that the fracture care codes (the most common ones used in pediatrics are 23500, 26720, 26750, 28490, and 28510) include casting or splinting and follow-up care for 90 days, and that therefore there would be no E/M code for the visit, unless some other illness was addressed at the
same visit.

This isn't, however, strictly correct. It is possible to bill for fracture care and for an office visit at the same time, using modifier -25 on the office visit. (See the modifier -25 description in box on page 39.)

Some payers will allow it (an office visit and a fracture care code) and some wont, says Laura Neuchterlein, senior policy analyst for the American Academy of Orthopedic Surgeons (AAOS), where the AAP referred us for clarification of this issue. You cant make a blanket statement about whether you can or cant use both.

The key element, says Neuchterlein, is what kind of decision-making went into the visit. Its not likely that the child came into your exam room and announced, I have a phalangeal shaft fracture of my thumb. Would you please perform closed treatment, no manipulation, thank you very much. Rather, you as a pediatrician must decide what is wrong or what might be wrong, order the x-rays, and proceed accordingly.

As long as you are making a decision about how to handle the fracture, about what kind of treatment it requires, and how youre going to manage the care, you are going to be performing an E/M services as well, says Neuchterlein. Can you even say that a simple fracture doesnt require an E/M code? No, responds the policy analyst. It depends entirely on the situation.

Note: Surgeons would not use the modifier -25 on the office visit if they were going to proceed with surgery; rather, they would use the modifier -57, which shows that they made a decision for surgery during that visit.

Casts and Strapping Codes

Furthermore, if you are only applying a splint as an initial measure, and then sending the child for further care elsewhere, you cant use the fracture care codes. This is the best time to be using an E/M code. While its true that some plans may argue that the E/M service is included in fracture care codes, E/M services are definitely not included in the strapping codes. You must use one of the casts and strapping codes, such as 29130 (application of finger splint; static) or 29550 (strapping; toes). The casts and strapping codes are used when the strapping is an initial service performed without a restorative treatment or procedure to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient, according to the CPT manual. These codes are also used during or after the period of follow-up care. Thus, the physician who cares for the child following the application of the initial splint (or cast or strap) should use the fracture code.

Utilizing Supply Codes

If, however, you are casting or strapping alone (such as in the case of a sprained ankle) and no other procedure is necessary (such as surgery, or reduction of a fracture or joint dislocation), you must use an E/M code, according to CPT. Splint supply is not included in the strapping codes, so CPT recommends you use 99070 for the splinting or casting supplies.

We strongly recommend the HCPCS codes, however, because 99070 is an unlisted supply code, and payers require an invoice to be attached before they will even think about paying it. In the February article, it was strongly suggested that you use the appropriate HCPCS supply code (such as A4570 for a splint), along with a description of what the splint is, and probably an invoice as well. Our experts stand by that recommendation. So the bottom line is, if you are applying a cast or a strap (or a splint) alone, with no other procedure, you should use an E/M code, the appropriate strapping code, and the appropriate HCPCS
supply code.

Two Fracture Care Coding Examples

Here are two scenarios from Thomas Kent, CMM, president of Kent Medical Management, Dunkirk, MD, which illustrate the ways to use fracture care codes.

Example 1: Preschool child injures finger as car door is closed. The history of the present illness (HPI) and a quick glance at the child will tell you that this is a problem-focused injury. The pediatrician examines only the hand and determines the finger is simply sprained and bruised. This would be low medical decision-making. The E/M code would be 99212 with a -25 modifier. You would use 29130 (application of finger splint; static) as the strapping code. Then use the HCPCS code A4570 for the splint. The same diagnosis codes would be on both the E/M and the strapping CPT codes: 842.13 is for sprain of the finger; E819 is for crushed between objects; and E849.0 is for location, home.

Example 2: Middle school child fractures finger during fall off bike. Multiple abrasions and contusions to the arm are treated; also, there must be an exam to rule out concussion or other injury.
The finger fracture treatment would be coded first as 26720 with the following diagnosis codes: 816.00 for fracture of phalanges, hand, closed; and E826.1 for non-motor vehicle accident.

Note: The splint or cast is included with this procedure.

The manner of the injury and possibility of additional injuries make this moderate to complex medical decision-making. The E/M service will probably justify a 99214 if properly documented. Use a -25 modifier on the E/M with the diagnosis codes 923.8 (contusion of upper limb, multiple sites); V71.4 (observation following accident); E826.1 (non-motor vehicle accident); and E884.1 (fall from cliff).