Pediatric Coding Alert

If you know what the carrier wants, you'll get what you want

A lot of the confusion about what to report for  treating a fracture stems from the lack of a policy on the issue from the Centers for Medicare and Medicaid Services (CMS). Experts recommend countering this information vacuum with research into carriers' individual policies.

"Back in July 2002, CMS did say that they would publish a memorandum soon on how to code for fracture and casting care," says Karen Marsh, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. "We're still waiting for that, so there continues to be controversy on how to code for fracture care."

"We usually report fracture care as an E/M service and report casting and splinting separately," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. "But we do code for fracture care sometimes, such as when manipulation is performed on an elbow or shoulder that needs to be popped back into place."

Still, Jackson says, the payer's policies are what drives her office's claims. In short: What the carrier wants, the carrier gets -- not a bad mantra in this uncertain coding area.

"What I do see more often than not is using fracture-care codes only if there is manipulation, but until we get a program memorandum that more clearly defines the issue, there's no single answer,"  Marsh says.

It may not seem fair, but the buck must stop with the coder when reporting in-office fracture care. Marsh stresses that it's vital to know your office's policy on fracture-care coding, as well as the policies of the insurance carriers you're dealing with.

Best bet: Before coding a fracture-care visit, check with the carrier about what they will and won't cover when reporting fracture care. Do this each time you deal with a different carrier, and document the carrier's individual policy on fracture-care coding in the company computer.

That way, you won't have to do all that legwork each time the pediatrician fixes a broken bone.