Podiatry Coding & Billing Alert

You could be missing more than $100 in deserved reimbursement.

How can you tell if a claim merits a fracture care code or an E/M code? It's usually hard to tell right away as experts agree that code selection will likely depend on a case-to-case basis. Take the following four factors into account to find the best fit the fracture treatment.

1. Match Fracture Treatment With Criteria

You'd know you should report fracture care, if the scenario meets the following criteria:

• The physician sees the patient for her initial visit for the injury (e.g., 826.x, Fracture of one or more phalanges of foot, and 838.xx, Dislocation of foot). 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 instance, if the patient was injured while on vacation, had surgery and now is home and seeking follow-up, you cannot bill fracture care).
• The physician provides a restorative treatment or procedure and plans to care for this injury for the next 90 days.

Example: A patient presents with pain and swelling in his ankle following a basketball injury that occurred the previous day. The podiatrist found the patient with a closed bimalleolar ankle fracture and performs closed treatment without manipulation.

Code it: You should bill 27808 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; without manipulation)) linked to 824.4 (Fracture of ankle; bimalleolar, closed).

2. Consider the Possibility of an E/M Service

Some cases call for you to report an E/M service (99201-99215, Office or other outpatient services ...) instead of fracture care. You should also consider billing the appropriate casting and strapping application codes (29000-29590), where applicable.

These criteria should clue you in to the appropriate codes:

• The fracture is old.
• There is a nonunion of the fracture.
• The fracture has healed or mostly healed.
• The physician doesn't provide a restorative treatment or procedure for which he goes to assume follow-up care for the next 90 days.
• The physician doesn't recommend follow-up visits.
• The physician refers the patient for a more extensive procedure, like open treatment with or without fixation.

Hidden trap: If you don't 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 an E/M code when you code application of casts and strapping (29000-29590) and an E/M service, you risk trouble on your claim.

Example: A physician straps an established patient's ankle after performing a level-two E/M. On the claim, report the following:

• 29540 -- Strapping, ankle and/or foot
• 99212 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision making,

Link modifier 25 to 99212 to show that the E/M and strapping were separate services.

To make it clear: If you're wondering whether to report 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]) in your claim, you should stop right there. CPT® 99070 would be part of the procedure, which means you shouldn't bill it separately.

3. Generate Larger Payouts with Fracture Care Codes

Don't get used to the habit of billing an E/M code and the applicable casting code all the time. If you missed the opportunity of reporting fracture care you could be losing at least $100 per claim. Learn from this scenario:

A child comes in after stubbing her big toe. The physician 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 reports no separate E/M service.

In this case, you have two options: 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation), and 29550 (Strapping; toes). These CPTs describe the same work performed by the physician, say experts. She makes no referral to the orthopedist and may see the patient for follow-up.

Smart move: By reporting fracture care with 28490, which has 4.21 RVUs and 90 global days, you'd be paid $143.30. On the other hand, 29550 has 0.9 RVUs and zero global days, which should pay you $30.63. A huge difference of $112.67 means you should go for 28490 rather than 29550.

4. Be Careful Reporting for Follow-Up Visits Carelessly

Fracture care codes may include related follow-up care, but it doesn't mean you will not report a code for any follow-up visits. It's always wise to look at the reason the patient presents for the visit, and base your code selection on the following:

If the E/M service during the global period relates to the original procedure, you should report the included follow-up care with 99024 (Postoperative follow-up visit, normally included in the surgical package ...) and a $0 charge.

When your physician sees a patient during the fracture care global period for an unrelated problem, add modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M service.