Breaking the Fracture Code

Coding Orthopedic Procedures in the Emergency Department

by Sarah Todt, RN, CPC-EDS
Emergency department (ED) physicians are often the first line in evaluating, diagnosing and treating injuries. On occasion, emergency physicians have an opportunity to provide additional services beyond typical evaluation and management (E/M). Due to the complexity of orthopedic injuries, ED coders must have a good understanding of anatomy and related orthopedic procedures.

Orthopedic Injuries

The severity of orthopedic injuries ranges from contusions and simple sprains to open fractures and dislocations. Treatment options depend on the type, severity, and location of the injury. Frequently, minor injuries only require supportive care such as rest, ice, compression, and elevation, documented as RICE. Supportive care is considered part of the E/M service and is reflected in the medical decision making under treatment options or risk.

Splints

Some injuries require additional treatment in the form of immobilization, which may be achieved by splint application. There are many different types of splints ranging from off-the-shelf prefabricated products to splints fashioned by providers. CPT® does not describe a specific type of material required for reporting splint application codes. Documentation should include the type of splint and an application note with a post-application assessment, which usually contains alignment and neurovascular status.

Fractures

Frequently, fractures result from high-energy injuries. Management of fractures in the ED range from supportive care such as ice and analgesia to emergent manipulation. When the care of the patient is directly transferred over to a consulting orthopedic surgeon typically the ED care is reported via E/M codes.
Occasionally, the ED physician provides fracture care services and these can be reported when certain criteria are met. First, the coder needs to know what types of fracture care the ED physician provides and secondly, the care should be equivalent to a specialist’s service.
There are two types of fracture care provided in the ED: non-manipulative and manipulative. Non-manipulative care is provided when fracture reduction is not clinically indicated and is described in CPT® as “closed treatment without manipulation.” Manipulative fracture care is provided when the physician restores alignment and is described in CPT® as “closed treatment with manipulation.” CPT® further defines some fracture care codes as: “open reduction” and “with anesthesia.” Both of these fracture care categories are generally reserved for surgical procedures performed in the operating room and are not usually reported by emergency medicine physicians. Keep in mind, open reduction is a description of the procedure not the injury.

Definitive Care

The fracture care codes described as “without manipulation” may be reported when the treatment is definitive. Generally, these fractures heal without surgical intervention and the care is equivalent to that of an orthopedic surgeon. Definitive care is associated with fractures of the nose, ribs, fingers, toes, and clavicle. For example, an uncomplicated fracture of a rib may be treated with pain medication, detailed discussions regarding healing and prognosis, and instructions on incentive spirometer use. This service may be reported with 21800 Closed treatment of rib fracture, uncomplicated, each which has a 90 day global period. The addition of modifier 54 Surgical care only is required if the patient is referred to another physician for follow-up care. Nasal fractures may also be treated with supportive care. A non-displaced closed fracture of the nose may be treated with prescriptions including pain medication and decongestants and are frequently reported with 21310 Closed treatment of nasal bone fracture without manipulation. This code has a “0” day global period and does not require a modifier.
Other definitive care may be provided for fractures treated with immobilization; for example, a non-displaced fracture of a proximal phalanx may be treated with splinting and is reported with 26720-54 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each; surgical care only. Splint codes are considered bundled with fracture care and should not be reported separately.

Restorative Care

Restorative care is captured with the CPT® codes described as “with manipulation.” ED physicians may perform reductions on certain displaced fractures; for example, the ED physician treats a patient with a mildly displaced Colles’ fracture. The case is discussed with orthopedic surgery, the ED physician performs the reduction and a splint is placed. At discharge, the patient is instructed to follow up with orthopedic surgery. This fracture reduction is reported with 25605-54 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation;
Neuro and/or vascular compromise increases the complexity. Often, the urgency of these injuries does not allow time for orthopedic surgery consultation. The ED provider needs to manipulate the fracture to restore the neurovascular status: for example, a patient presents with a bimalleolar fracture. Examination of the affected foot reveals decreased sensation, pulse and temperature. The physician performs a reduction to restore the neurovascular status and applies a splint. This procedure is reported with CPT® code 27810-54 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation; surgical care only. Following the emergent reduction, orthopedics are consulted to assume care.

Dislocations

Dislocation reduction is another orthopedic service provided on an emergent basis. Dislocation is a disruption of the joint and should not be confused with displaced fractures. These injuries require reduction to return the joint to normal function. Generally, The code sets with the descriptions of open reduction and “with anesthesia aren’t used when coding services for ED providers. Shoulder and hip dislocations are among the most frequently managed dislocations in the ED; however, physicians may also treat dislocations of other joints. Remember: hip dislocation reduction codes are unique as there is an additional classification related to post arthroplasty.
Orthopedic procedure codes represent a challenge for ED coders. Careful review of the record and clear understanding of the procedure is essential to proper code assignment for the provided services.

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