Pediatric Coding Alert

Fracture care coders, beware: If your pediatrician treats a fractured finger and applies a splint, do not report both procedures. Coding 26720 and 29130 violates the latest version of the National Correct Coding Initiative (NCCI) and will trigger a rejection.
 
Although some pediatric practices refer all fracture care to an orthopedist, other pediatricians treat minor fractures such as finger and clavicle fractures in the office, says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine PA in Medford, N.J. Pediatric coders whose physicians perform in-office fracture treatment should pay attention to NCCI, version 9.2, effective July 1.
 
Application Is Part of Fracture Code

NCCI's newest fracture coding bundles correspond to CPT's guidelines, says Marie Felger, CPC, a coding consultant and American Academy of Professional Coders-certified coding instructor with Joy Newby & Associates LLC in Indianapolis. "The guidelines at the beginning of the Musculoskeletal section and the Application of Casts and Strapping subsection both clearly state that the treatment of fracture and/or dislocation codes (21300-28675) include the first cast, splint or strap application," she says.

Now NCCI reinforces CPT's guidelines, says Lynn Cramer, RNC, practice manager at Eden Park Pediatrics in Lancaster, Pa. "The NCCI Edits bundle the corresponding cast and/or splint code into the fracture treatment code," Cramer says. Therefore, when you charge a fracture code, you should not also bill for applying a strap or splint to the same anatomic site.

Two Reasons Fracture Treatment Includes Application

Fortunately, because NCCI's bundle reinforces correct coding procedures, the new edit should not affect your practice's bottom line. The reason that both CPT and now NCCI disallow reporting a fracture care code with a related cast code is two-fold. First, the relative value units for fracture care include the costs associated with the initial restorative treatment and all of the subsequent care for that condition during the 90-day global period, Felger says. Second, per CPT, the fracture service includes the initial cast, splint or strap. "Therefore, fracture care/dislocation codes and application of casts and strapping codes are mutually exclusive and not separately reportable," she says.

To see how NCCI's bundles and CPT's guidelines apply to pediatric-fracture coding, consider the following situations.

Fracture/Splint Bundle: A 15-year-old female presents with a painful index finger that she jammed while playing basketball. The pediatrician sends the patient for an    in-office x-ray (73140, Radiologic examination, finger[s], minimum of two views), which she interprets as showing a hairline fracture of the middle phalanx (816.01, Fracture of one or more phalanges of hand; closed; middle or proximal phalanx or phalanges). The pediatrician treats the fracture (26720, Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) by applying a static splint for support (29130, Application of finger splint; static). Because the fracture treatment (26720) includes applying the initial splint (29130), you should report the fracture treatment (26720), not the splint application code (29130), according to CPT and NCCI.

Fracture Referral: Suppose an established patient presents with a more severe fracture that the pediatrician stabilizes but does not treat. For example, an 8-year-old boy falls off his skateboard and presents with a painful wrist. After taking x-rays of the wrist (73100, Radiologic examination, wrist; two views), the pediatrician determines the child has a Colles' fracture (813.41, Fracture of radius and ulna; lower end, closed; Colles' fracture). She does not treat the fracture but instead straps the wrist (29260, Strapping; elbow or wrist) to stabilize the injury until an orthopedist can provide treatment. Because the pediatrician stabilizes the injury rather than treats it, you should use the strapping or splinting (29125) code, depending on the treatment.

You should also report the appropriate E/M code, such as 99212-99213 (Office or other outpatient visit for the evaluation and management of an established patient ). Some insurers may require you to append modifier -25 to the E/M code to indicate a significant, separately identifiable E/M service from the strapping. Do not, however, use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), unless the insurance company requires it, says Richard Tuck, MD, FAAP, a pediatrician at Primecare Pediatric in Zanesville, Ohio.

Use Correct Coding Edits Across the Board

Although CPT already stipulates that the treatment code includes the initial cast, splint or strap application, many pediatric coders are unsure whether they should always adhere to NCCI guidelines. Because NCCI bases the fracture/application bundle on correct coding guidelines, the rule applies to all payers, Scott says.

Not all NCCI edits, however, require strict adherence. "The edits supposedly show the right way to code," Scott says. But CMS sometimes creates bundles for budgetary reasons that are not correct according to CPT specifications. For edits that are not based on correct coding guidelines, coding experts usually recommend billing to your financial advantage.

When CPT does not support an NCCI bundle, you may separately report the codes if the payer does not follow NCCI.

On the other hand, when billing payers that adopt Medicare's policies and follow NCCI, you have to abide by CMS' guidelines. "Otherwise, the insurer will not pay the claim," Scott says.