Pediatric Coding Alert

You can ethically boost claims $80 to $125 by reporting treatment instead of splint/strap

You won’t find a clear-cut answer to when you should report fracture care and when you should bill an E/M service and casting instead, but experts advise that one code set may make more sense than the other depending on the individual case. Take the following factors into account when making your decision to find the best fit for your claim.
 
Don’t stress: Payers don’t deny either code set as incorrect coding.

Consider Fracture Care for Global Care

When fracture care codes apply: When you’re wondering whether you should report fracture care, consider whether the case meets the following criteria:

 • You’re seeing the patient for her initial visit for the injury (fracture or dislocation).
 • The injury is recent enough that it has not already healed on its own.
 • The patient has not had surgery for this injury by another physician in a different practice. (For example, if the patient was injured while on vacation, had surgery and now is home and seeking follow-up, you cannot bill fracture care.)
 • You plan to care for this injury for the next 90 days.
 • The patient’s history should reveal whether the patient presented to the emergency department or another physician’s office for initial care and was later sent to your practice for further care of the fracture.

Example: A patient presents with pain and swelling in his ankle following a basketball injury that occurred the previous day. Your pediatrician diagnoses the patient with a closed bimalleolar ankle fracture (824.4) and performs fracture care without manipulation.
 
Solution: You report 27808 (Closed treatment of bimalleolar ankle fracture [including Potts]; without manipulation) linked to 824.4.

Opt for E/M and Casting in These Instances

When you shouldn’t bill fracture care codes: The fracture care codes would not be appropriate if the following criteria apply:

 • The fracture is old.
 • There is a nonunion of the fracture.
 • The fracture has healed or mostly healed.
 • Your doctor is not going to care for this fracture for the next 90 days.
 • The physician doesn’t recommend follow-up visits.
 • The physician refers the patient for a more extensive procedure like percutaneous pinning or open treatment with or without fixation.

In the above cases, you should bill the appropriate E/M service, such as 99201-99215 (Office or other outpatient visit ...), with the appropriate casting and strapping application codes (29000-29590) instead of a global fracture care code.
 
Remember: When you code application of casts and strapping (29000-29590) and an E/M service -- along with the casting supply HCPCS code(s) from the A or Q series or 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) -- you should 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.

Generate More Revenue With Same Work

If you’re in the habit of billing an E/M code and the applicable casting code instead of fracture care, you could be losing money to the tune of $80 to $125 plus. Action plan: Start rethinking your protocol for finger splint and toe strap coding.

Consider the work involved in splinting a finger by comparing 26750 (Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each) to 29130 (Application of finger splint; static) for a closed fracture of the distal phalanx (816.02). Often pediatricians will bill for placing a finger splint with an E/M service code and 29130.

But these cases usually meet the definition of fracture care, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP,
associate medical director for compliance and business affairs at EPG in Egleston, Ga. You place the same splint in either coding scenario. The pediatrician doesn’t refer the patient to an orthopedist and sees the patient for follow-up.
 
The difference: Billing 26750 rather than 29130 is a difference of $127.33. Medicare’s National Physician Fee Schedule pays unadjusted rates of $165.99 (4.38 transitional nonfacility total relative value units [RVUs]) for fracture care versus $38.66 (1.02 RVUs) for the splint alone.

The breakdown: Code 26750 has a 90-day global period compared to a 0-day global period for 29130. “Anytime the patient returns within 90 days to see how the fracture is doing, the follow-up care is included in the procedure price of the fracture care,” Linzer says. Because the evaluation and management service and finger splint option has zero global days, you would, however, bill an E/M service for follow-up visits.
 
After applying a splint, the pediatrician may or may not see the patient back in 10 days, Linzer says. So you can’t count on 29130 providing an opportunity to bill an extra E/M service for related follow-up care. To recoup the $127.33 difference, you’d have to perform at the initial visit a level-five established patient office visit (99215 pays $129.61 [3.42 RVUs]) in addition to 29130 -- an unlikely scenario -- or a level-four new patient office visit (99204 contains 3.92 RVUs and pays a Medicare equivalent rate of $148.66).
 
Now look at how reporting fracture care rather than  toe strapping can boost a claim by $88. Example: A child comes in after stubbing her big toe. The pediatrician looks at the x-ray, diagnoses a closed fracture (826.0), straps the toe to the adjacent one and tells the parent to have the child wear church shoes for a while for added protection. The physician codes no separate E/M service. Your options include reporting:

• 28490 -- Closed treatment of fracture great toe, phalanx or phalanges; without manipulation
• 29550 -- Strapping; toes.

The pediatrician performs the same work in both coding scenarios, Linzer says. She makes no referral to the orthopedist and may see the patient for follow-up. But reporting fracture care with 28490 pays $87.54 more than using the toe strap code. Code 28490 has 3.30 RVUs ($125.06) and 90 global days compared to 0.99 ($37.52) and 0 global days for 29550. 

Code In-Global Service Based on Reason

Just because fracture care codes include related follow-up care doesn’t mean you won’t report a code for these follow-up visits. Look at why the patient presents for the visit and code based on these guidelines:
 
1. If the E/M service during the global period is related to the original procedure, report the included follow-up care with 99024 (Postoperative follow-up visit, normally included in the surgical package ...) and a $0 charge. Example: Your pediatrician treated a patient for a distal finger fracture. The patient comes in to check how it’s healing. You should report 99024 because 26750 includes the follow-up care.
 
2. When your pediatrician sees a patient during the fracture care global period for an unrelated problem, such as swimmers’ ear (380.12, Acute swimmers’ ear), add modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the E/M service, such as 99213. “The E/M has to be for a whole different issue,” Linzer says.

Tip: In a group practice, flag the chart to make sure a fellow pediatrician includes follow-up care when the treating physician reported global fracture care, says Richard H. Tuck, MD, FAAP, a nationally recognized speaker on pediatric coding and pediatrician at PrimeCare of Southeastern Ohio. That way, the second pediatrician won’t accidentally use an office visit code to report follow-up care.