Primary Care Coding Alert

Coding fracture care is a lot like working a puzzle: Coders must identify various pieces throughout the treatment process and connect them properly to represent  accurately the services provided.
 
"A large number of variables affect which codes are assigned," explains Cathy Klein, LPN, CPC, senior consultant with Health Care Economics Inc., a consulting and practice management firm in Indianapolis. "Family practice coders need to be able spot four elements and integrate them into the overall service provided."

When reporting fracture care, coders should peruse the FPs notes carefully, reviewing the four areas:
 
1. Identify the fractured bone. The Surgery/Musculoskeletal System section of the CPT manual is organized by body part. Codes that describe procedures of the upper arm begin with 23930, for instance, with fracture care appearing as a subset and encompassing codes 24500-24685. Pelvis and hip joint codes begin with 26990, with fracture care encompassing 27193-27266.
 
Because there are numerous codes in this section and all fracture codes are not centralized in one spot, coders will need to search through each category to find the codes assigned for fractures.
 
2. Determine if reduction is open or closed. "Reduction is a term physicians use to describe how they put the affected bone back into proper position," says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement consultant and educator based in Lenzburg, Ill. "There are several methods physicians can use to accomplish this."
 
These methods include closed reduction or treatment, which means no incision is made, or open reduction, which indicates that the physician made an incision near the affected bone to reposition it. "A physician will sometimes treat the fracture percutaneously, which simply means he or she will insert some type of treatment device through the skin," Klein says.
 
For example, a simple fracture of the femur may be coded 27500 (closed treatment of femoral shaft fracture, without manipulation). If an incision is required, it may be reported with 27507 (open treatment of femoral shaft fracture with plate/screws, with or without cerclage).
 
Generally speaking, FPs treat fractures that only require a closed reduction. Open or percutaneous reductions are usually referred to an orthopedic surgeon.
 
3. Establish if manipulation is used. When deciding whether to use an open, closed or percutaneous reduction code, coders must note if the physician manipulated the bone to set it. Methods of manipulation may include twisting or pulling on limbs or joints, or applying pressure near the point of fracture, Mueller says. Most fractures treated by family physicians do not require manipulation.
 
In the example above with a broken leg, for instance, 27500 describes the service without manipulation. But, 27502 is defined as closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction.
 
One indication that the family physician manipulated or set the bone is documentation that multiple x-rays were taken. When the fracture is manipulated, the physician may order subsequent x-rays to ensure the bone has been repositioned properly. If the family physician dictated separate radiologic reports that were responsible for further care and treatment of the fracture, Mueller says, the x-rays may also be reported. Codes for x-rays are in the Radiology section of the CPT manual and are organized by body part within the diagnostic imaging category, i.e., 73000, radiologic examination; clavicle, complete.
 
4. Find out if fixation devices are used. "On occasion, a physician will need to use hardware to keep the fracture in a position that will promote healing and ensure maximum functionality," Klein says. "Fixation can be internal or external, depending on the type of break the physician is treating." External fixation could include splinting or traction, while internal fixation may consist of wires, screws, plates, nails and pins. Because most fractures treated by family physicians are closed and require no manipulation, family practice coders will rarely assign codes that reflect fixation devices.
 
Code 26608 (percutaneous skeletal fixation of metacarpal fracture, each bone) is a classic example of internal fixation with a broken finger.

When pulling these four elements together to report fracture care, coders must read the entire classification of applicable codes. Most body-site subcategories offer a broad range of codes and may distinguish between the type of fracture, i.e., bimalleolar or trimalleolar ankle fractures; location of the fracture on the bone, i.e., proximal or distal; use of anesthesia; and other diverse variables.

    
Four questions regarding coding fracture care are among those most often asked by FP coders:

1. Are there exceptions to the global period?
 
Fracture codes are considered global and therefore encompass normal follow-up care and cast removal. But in some situations, additional services may be billed, Mueller says.
 
For instance, a family physician sees a patient with a broken forearm and reports 25500 (closed treatment of radial shaft fracture; without manipulation). The patient returns two weeks later for a follow-up, which would typically be included in the fracture care global period. However, she states that the cast is too loose and the physician determines it must be replaced. Because this is not considered standard care, the recasting would be reported, assigning a code from the Body and Upper Extremity/Casts series, i.e., 29075, application; elbow to finger (short arm). A diagnosis code, in this instance, would be V54.8 (other orthopedic aftercare). Another exception to the global period may occur if the patient cracked the cast, requiring it to be replaced.

2. May a practice bill for casting supplies?
 
In addition to the services provided, coders may also report the supplies used for applying the cast, Mueller says. "You would assign either A4580 (cast supplies [e.g., plaster]) or A4590 (special casting material [e.g., fiberglass]). However, reimbursement for these is at the discretion of the payer."
 
Some payers do not recognize HCPCS codes, so use 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]). 

3. How does an FP code fracture care following an ED visit?
 
Family physicians may see a patient who was treated initially at an emergency department (ED) for a fractured bone. "The family physician will be able to bill for the global fracture care as long as the ED physician did not initiate this category of service when the patient visited the ED. Often, the ED physician will bill a visit and the cast application, which will allow the family physician to assign the global care code," Mueller says.

4. May a practice bill an E/M service and fracture care?
 
Generally speaking, fracture care codes specifically describe the treatment of the broken bone, Mueller says. "An office or outpatient visit may also be reported with the initiation of the fracture care, provided the family physician does the history, physical exam and medical decision-making to determine the need for any surgical procedure." Append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in this instance.