Orthopedic Coding Alert

Definitive Diagnosis Brings Correct Reimbursement for ED Ankle Fractures

When an orthopedist is called to the emergency department (ED) to treat an ankle injury, coders are often confused about which service they should charge for. First, the surgeon must make sure that the injury is properly diagnosed. Then, billing for ankle care becomes a question of Who bills for what?

Choosing the right diagnosis is the crucial first step. Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., says it is essential that the physician record more than a rule-out diagnosis in his or her notes. If the physician suspects an ankle fracture, Brink says, and the x-rays indicate just a sprain, he or she has to diagnose a sprain in the notes. The key, Brink adds, is to make sure there is a definitive diagnosis of the problem at the end of the day, rather than just an indication of what wasnt wrong. The rule-out will not work as a diagnosis. The orthopedists notes have to reflect what was actually wrong with the patient, even if the problem was less serious than originally suspected, as in the case of an ankle sprain rather than a fracture.

Common ED treatment scenarios for ankle fracture include:

1. Fractures requiring surgery. The ED physician asks an orthopedist to evaluate an ankle injury. The orthopedist diagnoses a displaced trimalleolar fracture, admits the patient to the hospital and schedules thepatient for open reduction and internal fixation (ORIF) later that day. The orthopedist reports the appropriate-level initial hospital care code (99221-99223) with modifier -57 (decision for surgery) appended to indicate that the decision for surgery was made during this encounter, and 27822 (open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 (... with fixation of posterior lip).

2. Fractures requiring closed treatment only. The ED physician asks an orthopedist to evaluate an ankle injury. The orthopedist examines the patient, reviews x-rays and diagnoses a displaced bimalleolar fracture. He or she performs a closed reduction with application of a short leg splint in the ED. The orthopedist reports the appropriate-level office or other outpatient consultation code (99241-99245) with modifier -57 appended, and also reports 27810 (closed treatment of bimalleolar ankle fracture, [including Potts]; with manipulation). No additional code is reported for application of the splint because, as CPT states, the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

The patient returns to the orthopedists office for follow-up 10 days later, and x-rays reveal that the fracture slipped. An ORIF is scheduled for the following day. The office encounter is reported with 99024 because this service is part of the global period for 27810. The subsequent ORIF would be reported using 27814 (open treatment of bimalleolar ankle fracture, with or without internal or external fixation) with modifier -58 (staged or related procedure or service by the same physician during the postoperative period) appended. This modifier is appropriate when the procedure performed during the postoperative period is more extensive than the original procedure, according to CPT. HCFA guidelines state, When a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately. Modifier -58 must be reported with the second procedure.

Additional ED Scenarios

The following situations are less common in ED care:

1. Postoperative management only. If a patient presents with a bimalleolar fracture (824.2 or 824.5) and there is no pulse in the foot and an orthopedist is not immediately available, the ED physician may treat the injury by reducing the fracture and applying the initial cast or splint. Because the ED physician performed a large portion of the global fracture treatment, he or she would report 27810. However, it is unlikely that the ED physician will provide the subsequent follow-up care and, therefore, modifier -54 should be appended. The orthopedist who assumes responsibility for the postoperative portion of the global period should also report 27810, but with modifier -55 (postoperative management only) appended.

2. Fracture care without follow-up. An orthopedist on call to the ED may or may not follow the patient after the fracture is set, depending on the patients wishes. Some patients may have a regular orthopedist with whom they are more comfortable, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., and choose for their post-ED care to be administered by that doctor. In cases like these, modifier -54 (surgical care only) should always be appended to the fracture treatment code to indicate the surgeon only provided the surgical care and will not supply the follow-up care.

Payers generally reimburse the first physician 80 percent for modifier -54 and the second physician 20 percent for modifier -55.

The global fracture treatment codes (27760-27826) should not be used by the orthopedist in the ED if he or she provides only temporary treatment or initial stabilization until the patients primary orthopedic surgeon can administer definitive care. By performing only initial stabilization, the orthopedist is not providing a majority of the surgical package and therefore should report an E/M service and/or cast application code (29425), not a fracture treatment code. The E/M code depends on the level of service provided and documented in the medical record.

3. Splint application with E/M. If the orthopedist examines the patient, diagnoses an undisplaced fracture and applies a temporary splint (29515, application of short leg splint [calf to foot]), its application can be coded and billed separately with the appropriate E/M code. The orthopedist may stabilize the ankle with the splint, and then have the patient come to the office for the casting once swelling has diminished.

4. Strapping, casting or splinting as separately billed services. If the orthopedist applies a cast in the ED setting, the casting material is usually supplied by the hospital. The exception to this may occur if the orthopedist brings his or her own casting materials to the ED, such as Goretex casting that may not be available at the hospital. In a case like this, bill 29425 (application of short leg cast [below knee to toes]; walking or ambulatory type) with A4590 (special casting material [e.g., fiberglass]) for the supplies. Stout says reimbursement for casting supplies varies a lot among commercial carriers, and Medicare reimbursement rules for casting supplies vary from state to state. Since there is no definitive set of rules as to what a Medicare carrier must pay for, Stout says, its best to check with your local Part B carrier. The casting supplies may be a reimbursable item depending on the carrier, but in the hospital setting, the orthopedist can only bill for the supplies and services that his or her practice provides.

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