ED Coding and Reimbursement Alert

Check RVUs before settling on the first fracture care code to report.

When your ED physician performs repairs of multiple fractures on the same patient in the same session, you can easily leave deserved reimbursement on the table if you don't mind the work units associated with each repair code.

"The rule of thumb in reporting multiple fractures is to list the procedure performed with the highest RVUs [relative value units] as primary, followed by the other procedures in descending RVU value order," Yvonne P. Bouvier, CPC, CEDC, senior coding analyst at Bill Dunbar and Associates, LLC in Indianapolis.

"This ensures that carriers will pay the procedure with the highest dollar value first, and at the highest percent of payment, followed by the lesser procedures paid at the common surgical reduction rates," she says.

Those reduction rates can wreak havoc with your bottom line if you're not careful, as all fracture care codes submitted beyond the first will be reimbursed at half their values.

Lose Around $75 By Miscoding This Encounter

The ED physician performs a level-three ED E/M and diagnoses a left calcaneal fracture and a left talus fracture. The physician provides closed treatment for both injuries, and the calcaneal fracture requires manipulation.

On the claim, you should report the following:

Potential fallout: The payer will pay a modifier 51-appended code at 50 percent its total value. Code 28405 is worth about $331 (9.17 transitioned facility RVUs multiplied by the 2010 Medicare conversion rate of 36.0791). The 28430 code is worth about $186 (5.16 RVUs multiplied by 36.0791.

So based on the face value of the two codes, your pay will be reduced by $93 (half of 28430 value). If you reverse the fracture care codes in this scenario, however, your pay will fall by about $165 (half of 28405 value).