ED Coding and Reimbursement Alert

Question:

California Subscriber

You'll need to know the difference between the two, because your CPT^® code choice is based on whether the physician performed open or closed repair.

Closed definition: When the physician performs closed fracture treatment, it means that she did not have to surgically open the fracture site in order to repair the break. So if the operative report indicates that the physician performed closed treatment of a patient's broken rib, you'd report 21800 (Closed treatment of rib fracture, uncomplicated, each) for the repair.

Open definition: When the physician performs open fracture treatment, she either: surgically opens the fracture site and performs internal fixation; or exposes the fracture site remotely and inserts an intermedullary nail. However, due to the equipment needed for the procedure and the high risk of infection, open fractures are typically fixed in the operating room, not the ED.

So if the thoracic surgeon performs an open repair on a patient's sternum, you'd report 21825 (Open treatment of sternum fracture with or without skeletal fixation) for the repair.

Modifier 54 alert: Nearly all ED fracture care claims include modifier 54 (Surgical care only), because the ED physician is only treating the acute fracture, not providing the follow-up care. CPT^® reports that you must append modifier 54 to your fracture care claims unless the ED physician performs all of the follow up services during the global period which is typically 90 days.