ED Coding and Reimbursement Alert

If, on the other hand, your ED physician only provides palliative care so that the patient can go see the orthopedist, you should not report F/D codes. If a patient presents with a severe ankle sprain (845.01) with a lot of swelling and reports shakiness, and the physician, who is not sure whether a bone is broken, splints the ankle and instructs the patient to see the orthopedist as soon as possible, you should only report the splinting, Brame says. You should also report a relevant ED E/M code, if applicable.

This time frame isn't set in stone, however, so first check that what your physician did complements the code selection, Sandham warns.

Question #2: What is the difference between open and closed treatment?

Answer #2: "Open" or "closed" treatment refers to the type of treatment, not the condition of the injury involved. Many coders mistakenly think the opposite, that you should report open treatment with open wounds and vice versa. This confusion "is one of the most misunderstood things in CPT," Brame says.

If your physician's documentation doesn't clarify the type of treatment rendered, default to the closed treatment option, Brame says.

Coders have the most difficulty coding treatments for open fractures, for which the physician can do either open or closed treatment, she states. Here is a typically difficult case: The physician doesn't further open the site where the open break occurred and doesn't need to do any internal repair, but instead simply manipulates the bone back into place, reducing the dislocation and possibly closing the wound. You would report closed treatment for this open fracture, Brame says instruction that may seem counterintuitive to some coders because it seems that an open break would require open treatment.

You should check your payer's policy and make sure it won't be confused by the closed treatment report because the service actually does require closing the wound, Sandham says. Closed reduction generally means the physician just put traction or manipulation onto the bone, he says, and the physician's procedure for an open fracture will entail more than this work. At the same time, the ED physician's work will likely not meet the definition of open reduction, during which the physician goes in and performs open operative repair, usually in the operating room.

Given this confusion, you should at least address closed treatment coding with your payers. ACEP describes open treatment as involving "a surgical incision to expose the fracture for direct visualization." According to ACEP, "An emergency physician usually provides closed treatment only, even when caring for an open fracture." If your payer challenges your code selection, consider presenting this answer as backup for your physician's work.

Question #3: Which diagnosis code should you list as primary when a patient has multiple fractures?

Answer #3: Report any fracture that is open or complicated by debris as the primary diagnosis, Brame says. If you have multiple fractures that fall into that category or none at all, report the fracture for the largest, longest bone first, she adds. For example, report a pelvic bone fracture (808.2) before an ulna bone fracture (813.01) unless the ulna fracture is open or complicated by debris (813.11).

If none of the fractures are open or complicated by debris and the bones are relatively the same size, report the fracture that required the most work. If you have a broken metatarsal (826.0), a broken tibia (823.00), and a radial ulna fracture (813.44) that need to be reduced due to dislocation, report the last fracture first, assuming the physician provides definitive care for each.

Question #4: I hear from orthopedic coders that they aren't appending their orthopedics follow-up fracture care services with modifier -55 (Postoperative management only). Should I still use modifier -54, or would our ED more likely see payment without the modifier?

Answer #4: You should follow the coding guidelines and most accurately describe what your physician did that is, append the modifier if the ED physician provided surgical fracture care. Payers will probably reimburse whichever claim yours or the orthopedist's gets to the payer first, Brame says, so report those services as soon as you can.

Question #5: What are the exact definitions of these descriptions found in fracture care documentation and codes: "without stabilization" and "with manipulation"?

Answer #5: "Without stabilization" means the physician renders palliative care that will support the patient until he or she sees the physician responsible for definitive care, Brame says. "With manipulation" means the physician needed to reduce the injury, which means the patient has a dislocated fracture or dislocation, she says. If you see these comments in your physician's notes, you can now select the correct code accurately and quickly. "Without stabilization" indicates that you shouldn't use a fracture care code, and "with manipulation" and "without manipulation" are descriptors in many fracture care codes.