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. Bone Up on the Musculoskeletal Section 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. Treatment Makes All the Difference Additional variables, such as the type of treatment, also exist. "Knowing whether the treatment is open or closed will lead to [...]