Orthopedic Coding Alert

Check out this rundown of open/closed repairs on ulnar/radial breaks.

When your orthopedist fixes an ulnar and/or radial shaft fracture, the treatment could be open or closed.

The code choice is no open and shut case, however; you’ll need more information on fracture anatomy, and other factors will also contribute to code choice.

Check out these closed and open ulnar/radial shaft fracture case studies, from Jeff Weintraub, MD, MBA, FAAEM,  practicing physician and business manager at Norwalk Hospital in Norwalk, Connecticut.

Closed Tx

A new patient presents after suffering a physical assault; he was struck in the mid-forearm with a hard object (e.g., bat, crowbar, nightstick), sustaining a mid-shaft ulnar (and/or possibly radial) fracture with angulation. X-rays reveal that the radial and ulnar bones are fractured. The skin over the injury is intact, and the surgeon performs no incision to treat the injury. The surgeon performs a manipulation of the fracture without need for an incision to straighten it and restore normal alignment. The surgical team then splints the injury to immobilize the fracture. The surgeon gives the patient fracture care teaching, addresses pain control, and tells the patient to follow up as an outpatient for postoperative care. Encounter notes indicate that a level four evaluation and management (E/M) service preceded the fracture repair.

Closed Tx Coding

For the surgery, you would report 25565 (Closed treatment of radial and ulnar shaft fractures; with manipulation). For the E/M service, you’d report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity … )

with modifier 57 (Decision for surgery) appended to show that the E/M led to surgery.

Specifics: “If the shaft fractures were not angulated or significantly displaced and did not require manipulation to restore normal alignment — but [the surgeon] provided immobilization, fracture care teaching, addressed pain, and excluded complications, then the codes would be 25560 for both bones, 25530 [Closed treatment of ulnar shaft fracture; without manipulation] for ulna only, and 25500 [Closed treatment of radial shaft fracture; without manipulation] for radius only,” says Weintraub.

Open Tx

To illustrate the difference between open and closed treatment, consider the above scenario, with the patient suffering a mid-forearm injury after an assault.

For open treatment of the same injury, “the difference is that in order to properly treat the fracture, the surgeon would take the patient to the OR, perform an incision under sterile condition, manipulate the fracture to restore normal alignment and, likely, also insert hardware to stabilize the fracture prior to immobilizing the bones,” explains Weintraub.

For coding of open surgical treatment of an ulnar/radial fractures in the above scenario, you’ll report 25574 (Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna). As with closed treatment, there are other options for open repairs based on anatomy and other factors.