Orthopedic Coding Alert

When a snowboarder falls, can you code the treatment?

In last month’s article “I.D. Open/Closed Before Reporting Vertebral Fx Fix,” we ran down the intricacies when coding surgery for patients suffering from vertebral fractures.

This month, we’ll put that information to work with a couple of clinical case studies.

Do this: Check out the following examples from Gregory Przybylski, MD, MBA, Chairman of Neuroscience at the Hackensack Meridian Health Neuroscience Institute at JFK University Medical Center in Edison, New Jersey. Try your hand at coding the scenarios yourself to test your vertebral fracture fix coding.

Scenario 1

A 72-year-old new patient sustained a minor fall at home, resulting in severe interscapular pain. They were evaluated in the emergency department (ED). Their neurological condition was normal. The radiologist performed thoracic radiographs, which showed a T8 compression fracture that was confirmed with noncontrast thoracic computed tomography (CT). Moderate-complexity medical decision making (MDM) by the surgeon included assessing the patient’s history of osteoporosis, review of the imaging, and comparing various treatment options. The surgeon then performed closed treatment of the thoracic vertebral body fracture with manipulation and external casting and discharged the patient home.

Coding for Scenario 1

For this encounter, you would report:

• 22315 (Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction) for the vertebral fracture repair
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the evaluation and management (E/M) service.
• Modifier 57 (Decision for surgery) appended to 99204 to show that the decision for surgery was made during the E/M
• S22.060A (Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture) appended to 22315 and 99214 to represent the patient’s fracture

Note: The radiologist would report 72070 (Radiologic examination, spine; thoracic, 2 views) and 72128 (Computed tomography, thoracic spine; without contrast material) for the imaging services.

Scenario 2

A 25-year-old snowboarder accidentally encounters an obstacle, resulting in a serious fall. Severe neck pain accompanied by transient paralysis and persistent arm paresthesias prompted the ski patrol to send them to the local ED. Plain radiographs showed a unilateral C67 facet fracture with dislocation, which was confirmed on cervical CT and magnetic resonance imaging (MRI). A spine surgeon evaluated the patient and found no spinal cord injury, but neurological evidence of unilateral triceps weakness. Recommendation for open treatment of the fracture dislocation was given. A posterior open cervical treatment was performed with reduction of the fracture, decompression of the C7 nerve root and posterior C67 arthrodesis with local bone graft and non-segmental posterior C67 spinal instrumentation. The patient was admitted to the hospital and discharged the following morning.

For this encounter, you would report:

• 22326 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical) for the fracture repair
• +22840 (Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)) for the instrumentation
• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment) for the arthrodesis
• Modifier 51 (Multiple procedures) appended to 22600 to show that the surgeon performed multiple procedures
• +20936 (Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)) for the autograft
• 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) for the inpatient evaluation and management (E/M) service
• Modifier 57 (Decision for surgery) appended to 99223 to show that the inpatient E/M led to the decision for surgery
• S12.500A (Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture) appended to 22326, +22840, 22600, +20936, and 99223 to represent the patient’s C67 fractured vertebra

Note: The radiologist would report 72050 (Radiologic examination, spine, cervical; 4 or 5 views) and 72125 (Computed tomography, cervical spine; without contrast material).