ED Coding and Reimbursement Alert

There might be a separate E/M — but don’t assume it.

Even the most seasoned coder can forget little details from time to time; details that might adversely affect the status of a fracture care claim.

So, brushing up on fracture care resources and claim fulfillment is always a good idea, even for coders that don’t think they need it.

Check out what Jaci Johnson Kipreos CPC, CPMA, CDEO, CEMC, COC, CPC-I, president at Practice Integrity, LLC in San Diego, had to say about simplifying and streamlining your fracture care coding without forgetting any of the essentials.

Know 20000 Series Advice

Any coder looking to get a handle on fracture care should start reading the introduction to the Musculoskeletal 20100-29999 section of the 2022 CPT^® manual. That’s where you’ll find a treasure trove of useful information.

“CPT^® provides great guidance at the beginning of the 20000 series. I think it’s important to know where to find your best information, and in CPT^® it’s beginning of that musculoskeletal section,” Kipreos says.

In the intro to the 20000 series, you’ll find the following information:

• Skeletal system diagram with bones labeled
• Anatomical breakdown of code groups; for instance, Shoulder (23000-23929)
• Muscular system diagram with muscles labeled
• Definitions for different terms used in musculoskeletal coding; for instance, “closed treatment,” “open treatment,” “manipulation,” etc.

Benefit: This information is a vital resource for coders who deal with fracture care claims, and should be marked clearly in your CPT^® book (if you’re still paper).

Know When Separate E/M’s Possible

Kipreos reminds coders that fracture care could be, but is not always, preceded by a separate evaluation and management (E/M) service. When looking for a separate E/M on a fracture care claim, you must be able to prove that the E/M service was significant and separate from the fracture care. The standard preoperative work that is contained in the work units for fracture care codes cannot be counted toward a separate E/M.

Important: Because an E/M is potentially possible for each fracture care claim, you’ll need to know the global periods for each of the fracture care codes. That’s because the E/M modifier will differ depending on the global for the fracture care code; E/M services that accompany a surgery with a minor (0- or 10-day) global require 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). If the surgery has a major (90-day) global, then you’ll opt for modifier 57 (Decision for surgery) on the E/M.

Separate E/M: So, let’s say a patient reports to the ED complaining of left wrist pain. After performing a detailed history and examination, the emergency physician diagnoses a fractured wrist. Notes indicate moderate medical decision making (MDM). The ED physician then perform closed treatment of a single carpal bone without mention of manipulation, explains.

“A 99284 [Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity…] would typically be reported for the ED care that goes into evaluating the patient, reaching the diagnosis, the mechanism of injury, co-morbidities, screening for other injuries per the EMTALA [Emergency Medical Treatment and Labor Act] requirements,” explains Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national coding and billing company.

Also: New language in the 2022 CPT^® code set also reminds coders that if the person providing the initial treatment for a fracture or dislocation will not be providing the subsequent treatment of the global surgical package, modifier 54 (Surgical care only) should be appended to the fracture or dislocation treatment codes.