ED Coding and Reimbursement Alert

Tip: Modifier 54 is a necessity on most fracture claims  When a patient reports to the ED for fracture care treatment, coders will need to be on the lookout for more than just broken bones -- they also need to know if the fracture is open or closed, whether the doctor had to manipulate the injury, and the level of evaluation and management service (E/M) the physician provides in addition to the repair.

Without this information, coders run the risk of undercoding their fracture care encounters. Follow these four steps to the proper fracture care code choice: Step 1: Answer Open/Closed Question The initial step in coding any fracture care claim is deciding whether the physician treated an open or closed fracture, experts say.

-A coder must understand the difference between open and closed treatment in order to select the proper CPT code,- says Sharon Hathaway, CPC, coder at Danbury Hospital in Danbury, Conn.

ED physicians typically perform closed fracture treatment. Closed treatment means that the fracture site is not surgically opened by the treating physician. Open fracture care takes place when the physician surgically opens the fractured site and internal fixation takes place, or the physician remotely exposes the fractured bone to allow insertion of an intermedullary nail.

Whereas ED physicians deliver important and meaningful closed fracture care, open procedures are typically performed in the operating room due to the need for complex equipment and the risk of infection. 

Warning: Don't assume that a laceration near a fracture site makes the encounter an open fracture repair.  -Often, a patient will have a laceration and a fracture in the same area. But an open wound does not mean an open fracture; the patient could have a closed fracture and a laceration, which is two different procedures,- Hathaway says.

Step 2: Find Out if Physician Used Manipulation Once you have decided if the doctor treated an open or closed fracture, you need to decide if he used manipulation to treat the fracture. The ED physician will use manipulation on a displaced fracture, when -the bone is broken and needs to be realigned at the ends,- says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

If the fracture is nondisplaced, then the bones are close to or in anatomic alignment, and manipulation is often unnecessary. According to Thomas, you-ll see more nondisplaced fractures in the ED than displaced ones.

Example: The operative notes indicate a patient has a closed hairline fracture in his left clavicle. These -crack in the bone- breaks do not require manipulation because they are not displaced. On the claim, report 23500 (Closed treatment of clavicular fracture; without manipulation) for the encounter.

But if the notes state that the doctor had [...]