ED Coding and Reimbursement Alert

The break of a bone does not always mean a fracture code.

A patient presents to the ED with a broken bone. The physician confirms the fracture, treats the patient and sends him home. This is automatically a fracture care claim ... right?

Wrong: Eliminate misconceptions about your ED physician's fracture care treatment with the following fact or fiction challenge.

Fact or Fiction? Fractured Bone = Fracture Care

Fiction. Patients with broken bones don't always receive reportable fracture treatment in the ED, confirms Yvonne P. Bouvier, CPC, CEDC, senior coding analyst at Bill Dunbar and Associates, LLC in Indianapolis. The ED physician might make the patient more comfortable and send her to the orthopedist for definitive fracture treatment, for instance.

"For the ED physician to perform fracture care, she should provide the same care as an orthopedist would," explains Bouvier. If the physician does not provide care on par with the orthopedist, use the appropriate E/M code.

A patient reports to the ED with a swollen right wrist. During an expanded problem focused history and examination, which includes a wrist x-ray, the physician confirms a closed comminuted carpal fracture. The physician puts the patient's wrist in a splint and refers her to an orthopedist for follow up the next day. In this instance, the physician only provided comfort care, so you should report the following for the claim

Fact of Fiction? Manipulation Matters

Fact. The code you choose might specify whether manipulation occurred or not, such as 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each).

Definition: "Manipulation is an attempt to maneuver the bone back into proper alignment. The physician may bend, rotate, pull or guide the bone back into position during manipulation," explains Gwyn Kehrle, CPC, coder for New Jersey's Saint Barnabas Health Care System

Good tip: For fracture care coding involving manipulation, look for a note "stating that a reduction was performed typically along with an x-ray before [the manipulation] to show a displaced fracture; also, include a post-reduction x-ray to show proper alignment has been achieved," Kehrle comments.

Consider this detailed clinical scenario, courtesy of Bouvier.

Example: A patient presents with painful second digit of his left hand after being hit with a baseball. The physician documents a detailed history and performs a detailed exam, along with moderate medical decision making. The physician obtains a two-view x-ray and notes a displaced fracture of the shaft of the middle phalanx. The physician obtains anesthesia with digital block, and then manipulates the fractured finger back into place. After the procedure, the physician obtains another two-view x-ray to ensure alignment. She then places the patient's finger in a splint and instructs him to follow up with a local orthopedist.

On this claim, you'd report the following:

Fact or Fiction? Most EDs Perform Open Fractures Often

Fiction. An ED physician could provide treatment for an open fracture in certain situations, but your ED providers will perform closed fracture treatment most of the time, confirms Kehrle.

Definition: An open fracture occurs when the skin is perforated and there is an open wound down to the site of the fracture. Most open fractures would be referred directly to the orthopedist for operative intervention, and efforts are made to perform surgical treatment in a timely fashion to reduce the risk of infection. Treatment could consist of debridement of both unhealthy soft tissue and bone fragments, and wound washing with large volumes of sterile water most often containing antibiotics," Bouvier explains.

In a nutshell: "If the fracture requires open treatment, then the ED physician will [usually] stabilize the patient and send them to the OR," Kerhle says.

Before choosing a code for treatment of an open fracture, check with the physician to be sure you are not miscoding.