5 Tips Lead to Stress-Free Wrist and Forearm Closed Fracture Coding
Hint: Don’t forget to consider using modifiers 54 and 57 when warranted. Most fractures treated in the emergency department (ED) are closed fractures, which means the fractured bone hasn’t broken the skin or protruded out of it. But differentiating these closed fractures from those that break the skin (known as open fractures) is just the tip of the iceberg when it comes to selecting the right codes for addressing these conditions. Two common types of fractures that bring patients to the ED involve broken wrists or forearms, which often occur when patients try to break their fall. For instance, if a person falls out of a chair, they may try to land on their hands so they won’t hit their head. In some cases, the resulting pressure on their wrist and forearm can lead to a fracture. Check out five tips that will help you report the right codes when your ED provider diagnoses and treats closed fractures of the wrist and forearm. Tip 1: Know Which Bones Are Affected When you’re looking for diagnosis and procedure codes for forearm and wrist fractures, you may be surprised to see terminology you don’t recognize in the code books or the documentation. The following terms point to anatomical locations covered by forearm and wrist fracture codes: You may see a wide range of terms used in your provider’s documentation when they refer to forearm and wrist fractures, but these are among the most common. For instance, suppose an 8-year-old patient presents to the ED with a sore right wrist after falling off their bike and landing on their hand. The provider diagnoses a greenstick fracture of the right ulnar shaft. For this encounter, you’ll report S52.211A (Greenstick fracture of shaft of right ulna, initial encounter for closed fracture). Tip 2: Check the Closed Fracture Terms Just as you may not see the terms “wrist” or “forearm” in the documentation or the code book, you may also not be able to spot the term “closed fracture” in every situation. Your provider may instead document some of these terms to describe a closed fracture: For example, a patient presents to the ED with left wrist pain after trying to push a motorcycle up a hill. The provider finds that the patient has a linear fracture of the radial shaft, in which the bone is broken but still in its normal position. In this situation, you’ll report S52.392A (Other fracture of shaft of radius, left arm, initial encounter for closed fracture). Tip 3: Confirm Treatment Method Once you confirm that a fracture is closed, it’s important to determine whether the treatment method is closed or open. Closed treatment means that the ED provider doesn’t surgically open the fracture site to repair the injury. In most cases, the ED performs closed fracture treatment, meaning the provider sets the fracture by splinting, strapping, or casting it. They may also use manipulation (manual force) to reduce the fracture (bring it back into position). Not every closed fracture is treated using closed treatment, so you should review the documentation carefully to evaluate whether closed treatment was performed. For example, suppose a patient presents to the ED with left wrist pain after falling during a basketball game. The provider diagnoses the patient with a carpal scaphoid fracture affecting the middle third of the bone, and then reduces and splints the fracture. Reduction is necessary because the bone is displaced. In this case, you’ll report 25624 (Closed treatment of carpal scaphoid (navicular) fracture; with manipulation). For your diagnosis code, you’d report S62.022A (Displaced fracture of middle third of [navicular] scaphoid bone of left wrist, initial encounter for closed fracture). Tip 4: Look to Modifier 54 for Orthopedist Follow-Up In some cases, the ED physician will treat the fracture and then advise the patient to see an orthopedic specialist later on for a follow-up, which may include additional treatment, monitoring whether the fracture is healing properly, and eventually removing casts or other stabilization materials. Because your ED physician isn’t providing the follow-up care, then you won’t collect for the entire fracture care service. Instead, you’ll split the fee with the orthopedist who performs all of the follow-up. In these situations, you’ll need to append modifier 54 (Surgical care only) to the fracture care code. The orthopedist will append modifier 55 (Postoperative management only) to fracture care code so the insurer knows they only performed the aftercare. Tip 5: Check Modifier 57 for E/M If your ED provider performs an evaluation and management (E/M) service before repairing the fracture, append modifier 57 (Decision for surgery) to the E/M code 99281-99285 (Emergency department visit for the evaluation and management of a patient …) to show that the provider made the decision to perform fracture care during the E/M service. Why 57? All of the forearm and wrist repair codes have a 90-day global period (major surgery). For that reason, you’ll append modifier 57 to any E/M service performed with these codes. “Without this modifier, your visit will be denied as included in the global package of the surgery,” the Centers for Medicare & Medicaid Services (CMS) says in its >“Billing and Coding: Fracture Care” article A53322. Torrey Kim, Contributing Writer, Raleigh, North Carolina
