Primary Care Coding Alert

Capitalizing on reimbursement for treating simple fractures in the primary-care setting depends on the family physician coder's ability to pinpoint the correct code out of CPT's vast musculoskeletal system section. Fusing together five elements will fix your mind on the proper fracture code.

Although family physicians (FPs) usually refer complicated fractures to orthopedic specialists or send the patient to the emergency room, they frequently treat simple fractures, dislocations or manipulations in the office. Therefore, proper coding of the initial fracture care will help ensure your practice receives fair reimbursement in these cases, says Susan Welsh, CPC, PMCI, director of coding and education for HCA Physician Services and former billing coordinator for the department of orthopedics at Vanderbilt University in Nashville, Tenn.

To correctly code these scenarios, a basic understanding of the musculoskeletal maze is crucial. Fracture codes are spread throughout the musculoskeletal section (20000-29999). CPT organizes the codes starting with the head and working down the body. For instance, skull, facial bones and temporomandibular joint fractures are in the front of the section (21300-21497). FPs more typically treat fractures of the upper arm or elbow (24500-24685) or forearm and wrist (25500-25695). Hand and finger fractures begin with 26600 and end with 26785. The section then progresses to fractures and/or dislocations of the pelvis and hip joint (27193-27266), femur (thigh region) and knee joint (27500-27566), leg (tibia and fibula) and ankle joint (27750-27848) and concludes with foot and toes (28400-28675).

Within each of these sections, specificity is the key. Correct coding requires you to identify the precise bone affected. For instance, when an FP treats a lower-limb fracture, you must determine whether the fracture occurred on one of two leg bones: the tibia (the medial and larger of the two bones) or the fibula (the lateral and smaller bone). Ankle fractures are more complicated, forcing a distinction between the type of fracture, bimalleolar or trimalleolar, as well as the location of the fracture on the bone, proximal (closest to the trunk) or distal (farthest from the trunk).

In addition, anesthesia plays a role in code selection. Whether the physician administers anesthesia may make the difference between two codes, such as 27830 (Closed treatment of proximal tibiofibular joint dislocation; without anesthesia) and 27831 (... requiring anesthesia). In the physician's office, you will rarely report the anesthesia component. "Anesthesia" in CPT is generally understood to mean general anesthesia, which most FP's offices are not set up to administer. Therefore, the physician or nurse will typically administer conscious sedation rather than anesthesia.

Additional variables, such as the type of treatment, also exist. "Knowing whether the treatment is open or closed will lead to correct procedural coding," Welsh says. When a physician surgically opens the fractured bone, views the bone ends and uses internal fixation, he or she employs an open treatment, according to CPT's introductory notes to the musculoskeletal system. And if the doctor opens the fractured bone remote from the fracture site and inserts a nail, the procedure also qualifies as open. On the other hand, closed treatment means that the doctor did not surgically open the fracture site.

Unless your practice has outpatient surgery facilities, your FP will usually provide only closed fracture care. "Patients who sustain open fractures will probably go straight to the emergency room, rather than the office," Welsh says. Thus, if the notes do not indicate the type of wound, code a closed treatment instead of an open treatment, she advises.

Consequently, the element that you need to determine next is whether the case involves manipulation. "Fracture displacement is the key," Welsh says. When a fracture is not displaced, it is close to or in anatomic alignment. Consequently, the physician will not have to perform manipulation to treat the break. But, if the fracture is significantly out of place, the FP may need to "move," "distract," "reposition," "realign" or "apply tension" to manipulate the displaced bone into correct anatomic position, Welsh explains. In the case of minimal misalignment, as often occurs with incomplete fractures, the physician may not need to perform any manipulation.

For instance, a child falls off his bicycle and fractures the middle phalanx bone of his index finger. X-rays show a hairline fracture that is relatively in alignment. The physician reduces the bone. Because no manipulation is involved, you should report 26720 (Closed treatment of phalangeal shaft fracture ... finger or thumb; without manipulation, each). In contrast, if the doctor had to reposition the displaced bone, you would instead assign 26725 ( with manipulation, with or without skin or skeletal traction, each).

The physician also may employ a third technique to fix the bone. In complicated cases, the doctor may use percutaneous skeletal fixation to keep the fracture in proper position, Welsh explains. The physician may use external fixation, such as skeletal pins plus an attaching mechanism, or internal fixation, for instance wires, screws, plates, nails and pins. Because FPs rarely treat complicated cases that involve fixation, you will probably not have to use these codes.

Instead, you will more likely have to code for the FP evaluating but not treating a fracture. "In which case, you must determine whether the physician has simply applied a cast or splint, or is assuming the entire fracture care," says A. Clinton MacKinney, MD, MS, the American Academy of Family Physician representative to the AMA CPT advisory committee.

When dealing with open fractures and complex wounds requiring manipulation or fixation, the FPmay provide initial stabilization only to protect the fractured bone and to provide pain relief and refer the patient to an orthopedic specialist or the emergency room (ER) for fracture treatment. If the FPdoes not assume on-going or comprehensive care for the fracture, you should use the initial application of casts and strapping codes (29000-29590), rather than the fracture care code, MacKinney says.

For instance, a young woman presents with a fractured shoulder from falling down stairs. X-rays show that the woman fractured her greater humeral tuberosity. The FP does not surgically repair the fractured tuberosity, but applies a long arm splint to stabilize the shoulder and arm until an orthopedic surgeon can treat the patient the next day.

Because the doctor did not treat the fracture, reporting a fracture care code is incorrect. In this case, the physician rendered the initial care only and provided no other procedure or treatment. Consequently, the casting and strapping codes appropriately describe the service, MacKinney says.

Therefore, you should report the splint application (29105, Application of long arm splint [shoulder to hand]) and the payer-preferred supply code, such as Q4017 (Cast supplies, long arm splint, adult [11 years +], plaster), Q4018 (Cast supplies, long arm splint, adult [11 years +], fiberglass) 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]). In addition, you should assign the appropriate-level E/M service, such as 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ) for the physician's history, evaluation and medical decision-making prior to applying the splint. Append the office visit code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a significant, separately identifiable E/M from the splint application.