Orthopedic Coding Alert

An orthopedic injury can seriously impact a child's physical maturity. Coding for these injuries is often challenging, considering the variety of playground accidents and sports injuries to which active youths are prone.

Joanne Simmons, CPC, surgery coordinator at Nemours Children's Clinic in Orlando, Fla., reports that the most common sports-related injuries among pediatric patients are fractures of the humerus and femur. "Kids seem to fracture their humerus fairly frequently by falling off playground equipment or bicycles," says Simmons. The two most common fractures among children, she notes, are supracondylar fractures of the humerus (812.41) and fractures of the femoral shaft (821.xx).
 
Elbow fractures are common among youths who participate in playground or intramural sports. Damage to major vessels and nerves can occur, and some patients will require surgery to correct the problem. Dislocation of the elbow is another common injury, often seen in conjunction with fractures of the medial epicondyle of the humerus (812.43, Fracture of humerus; lower end, closed; medial condyle), fractures of the neck of the radius (813.06, Fracture of radius and ulna; upper end, closed; neck of radius, or 813.16, upper end, open; neck of radius) or injury to the median or ulnar nerve (955.1, Injury to peripheral nerve[s] of shoulder girdle and upper limb; median nerve, or 955.2, ulnar nerve). Any dislocation should be treated promptly, rehabilitation should be introduced gradually and the patient should not return to the sporting activity until he or she has regained a full range of movement.

Procedural coding for sports-related injuries and for those such as Simmons describes is relatively straightforward; however, coders should be certain, if the orthopedic surgeon does not do his or her own coding, that the physician's description of the injury is accurate. "It really helps when your physicians do their own coding," says Simmons. But when this is not the case, their notes must clearly describe the injuries.
 
For example, if a 6-year-old patient presents with a femoral fracture, the likelihood is great that the fracture may have occurred at the epiphyseal growth plate (the part of the still-growing bone that controls its eventual length). An epiphyseal injury can have long-term impact on the patient's development; thus, codes for its repair are different from those of a "normal" fracture. Repair codes in these cases include 27516 (Closed treatment of distal femoral epiphyseal separation; without manipulation), 27517 ( with manipulation, with or without skin or skeletal traction) and 27519 (Open treatment of distal femoral epiphyseal separation, with or without internal or external fixation).

Children who participate in gymnastics, hockey, diving and wrestling can develop injuries from overuse. The patient may report with tenderness in the triceps (729.5, Pain in limb). The orthopedist completes the E/M visit for a new or established patient (99201-99215) and orders x-rays. Review of x-rays at a subsequent visit results in a diagnosis of fragmentation of the epiphysis (813.01, Fracture of radius and ulna; upper end, closed; olecranon process of ulna, or 813.11, upper end, open; olecranon process of ulna). The physician orders the patient to rest from activities affecting the upper arm; after a follow-up visit three months later, the patient is significantly improved and released from the orthopedist's care for that particular episode.
 
Osteochondritis dissecans of the humeral capitellum (732.3, Juvenile osteochondrosis of upper extremity) is another frequent orthopedic injury in children that can result from overuse. Little League pitchers and gymnasts often present with such an injury. The child may present with elbow pain (719.42, Pain in joint; upper arm) and swelling (729.81, Swelling of limb) and, in some cases, may be unable to extend the elbow. The orthopedist orders x-rays; an MRI or CT may also be required to fully diagnose the condition. The condition may be advanced to the point that there are loose bodies in the elbow (718.12, Loose body in joint; upper arm). Treatment would involve limiting weight bearing and use of the elbow; if foreign bodies are present, surgery or arthroscopic surgery to remove them would be performed and coded 24101 (Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body) or 29834 (Arthroscopy, elbow, surgical; with removal of loose body or foreign body).

Orthopedic practices that work with children are also faced with a dilemma when it comes to fracture care coding. The options are either to code for an E/M service and charge for casting or to bill the global service fee for a nondisplaced fracture.
 
For instance, if a child reports with a fractured wrist (813.42, Other fractures of distal end of radius [alone]) from a soccer injury, the orthopedist may opt to code for an E/M visit and charge the fee for casting the wrist (29085, Application, cast; hand and lower forearm [gauntlet]) rather than the global code for fracture care. This method of coding, per the introduction to the Application of Casts and Strapping section of CPT 2002, is appropriate only when the orthopedist will not be assuming "subsequent fracture, dislocation or injury care" for the patient. In other words, if the patient's pediatrician sends him or her to the orthopedist for casting then expects to resume care for the injury, the orthopedist should bill the E/M and casting codes.
 
He or she can also bill for casting supplies, using 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]).
 
The other option is for the orthopedist to bill a global fracture care code (e.g., 25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation) instead of the E/M and casting codes. The orthopedist would follow the patient until the injury was resolved and wrap all subsequent visits into the global fracture code.
 
Terry Fletcher, BS, CPC, CCS-P, an independent coding and reimbursement specialist in Dana Point, Calif., suggests this is probably the best route for orthopedists to take. "From a purely reimbursement standpoint, the global fracture care codes have a higher level of reimbursement than E/M plus casting," she says. "Children are typically seen only two or three times during the global period, and the physician can charge for any recasting, if necessary, and any materials on the follow-up visits."
 
With fracture care codes, the orthopedist can still bill for supplies using 99070.
 
Fletcher points out that with children with minor fractures and sprains, it is "difficult if not impossible" for the physician to reach an E/M service higher than a level two. "There are not enough history or examination components required for children to reach a higher level of service," she says. An orthopedist who assumes all  follow-up care for a patient can ensure that the injury is treated to their satisfaction.