ED Coding and Reimbursement Alert

Did you know traction can accompany closed fracture treatment?

When your ED physician performs closed fracture treatment, several refinement gears need to start grinding in the mind of the coder.

Why? You’ll have a series of questions to answer surrounding the treatment of the fracture before you can close out the claim. These questions have answers, and we’ve got an expert to guide us to that place.

Check out this Q&A on closed fracture treatment with answers provided by Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor during her HEALTHCON 2022 session “Orthopedic Procedure Coding in the Office.”

Report Closed Treatment? Yes

The first step in coding for closed treatment fractures is knowing its definition for coding purposes. “In closed treatment, the fracture site is not surgically opened. It can be performed with manipulation, without manipulation, or with or without traction,” explained Clements.

Report Splinting/Casting? Probably not

During closed treatment, you likely won’t be able to report any casting/splinting/strapping, Clements confirms.

“This service is always bundled into restorative treatment reported on the same date of service,” she says; however, “cast, splint and strapping may be reported when the service is performed without definitive treatment, or it is a replacement procedure performed during or after the post-op period.”

And when it comes time for the cast/splint/strap to come off, the removal is bundled into the fracture care package when performed by the same group practice.

Code Separate E/M? Probably

In the ED setting, you’ll almost always have a separate evaluation and management (E/M) service in addition to the closed treatment. Patients who report to the ED have to undergo certain E/M elements before the provider can make a treatment decision; those elements typically add up to a separately reportable E/M. These E/Ms would likely fall under the ED E/M code set 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making…) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/ or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…), but other E/Ms are possible prior to fracture care.

Best bet: Make sure you can identify a separate, significantly identifiable E/M prior to the decision for surgical treatment before considering coding a preoperative E/M. If you’re unsure what might constitute a separate E/M, check with your provider and/ or payer.

Include Modifier? Maybe

When it comes to modifiers, Clements listed several that you might use on your closed fracture treatment claims:

E/M Modifiers

These modifiers could be in play when coding E/Ms associated with a closed fracture treatment scenario:

• Modifier 57 (Decision for surgery)
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)
• Modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)

Surgical Modifiers

These modifiers could be in play when coding separate surgical services associated with a closed fracture treatment scenario:

• Modifier 50 (Bilateral procedure)
• Modifiers RT (Right side) and LT (Left side)
• Modifiers FA (Left hand, thumb) through F9 (Right hand, fifth digit)
• Modifier 54 (Surgical care only)
• Modifier 55 (Postoperative Management Only)

Include Documentation? Yes

As with all claims, Clements stressed the importance of documentation for closed fracture treatments during her HEALTHCON presentation. “All procedures performed … at the patient’s bedside are required to have a note. The procedure note can be documented within the clinic note. It does not need a separate report,” she said.

The procedure note may include:

• Consent
• Location
• Indications
• Preparation of site including local anesthetic
• Instrumentation (when applicable)
• Medication name and dosage (when applicable)
• Size and (when applicable)
• Toleration of procedure.