Orthopedic Coding Alert

There might be a separate E/M — but don’t assume it.

Orthopedic coders are used to seeing a lot of fracture care claims come across their desks. But even the most seasoned coder can forget little details from time to time; details that might adversely affect the status of a fracture care claim.

So, brushing up on fracture care resources and claim fulfillment is always a good idea, even for coders that don’t think they need it.

Check out what Jaci Johnson Kipreos CPC, CPMA, CDEO, CEMC, COC, CPC-I, president at Practice Integrity, LLC in San Diego, had to say about simplifying and streamlining your fracture care coding without forgetting any of the essentials.

Know 20000 Series Advice

Any coder looking to get a handle on fracture care should start reading the introduction to the Musculoskeletal 20100-29999 section of the CPT^® manual. That’s where you’ll find a treasure trove of useful information.

“CPT^® provides great guidance at the beginning of the 20000 series. I think it’s important to know where to find your best information, and in CPT^® it’s beginning of that musculoskeletal section,” Kipreos says.

In the intro to the 20000 series, you’ll find the following information:

• Skeletal system diagram with bones labeled
• Anatomical breakdown of code groups; for instance, Shoulder (23000-23929)
• Muscular system diagram with muscles labeled
• Definitions for different terms used in musculoskeletal coding; for instance, “closed treatment,” “open treatment,” “manipulation,” etc.

Benefit: This information is a vital resource for orthopedic coders, and should be marked clearly in your CPT^® book (if you’re still paper).

Know When Separate E/M’s Possible

Kipreos reminds coders that fracture care could be, but is not always, preceded by a separate evaluation and management (E/M) service. When looking for a separate E/M on a fracture care claim, you must be able to prove that the E/M service was significant and separate from the fracture care. The standard preoperative work that is contained in the work units for fracture care codes cannot be counted toward a separate E/M.

Important: Because an E/M is potentially possible for each fracture care claim, you’ll need to know the global periods for each of the fracture care codes. That’s because the E/M modifier will differ depending on the global for the fracture care code; E/M services that accompany a surgery with a minor (0- or 10-day) global require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). If the surgery has a major (90-day) global, then you’ll opt for modifier 57 (Decision for surgery) on the E/M.

Separate E/M: So, let’s say a new patient reports to the orthopedist complaining of left wrist pain. After evaluative measures that constituted low-level medical decision making (MDM), the orthopedist diagnoses a fractured wrist. They then perform closed treatment of a single carpal bone without mention of manipulation.

For this claim, you’d report:

• 25630 (Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone) for the fracture care
• Modifier LT (Left side) appended to 25630 to indicate laterality, if the payer requires it
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 57 appended to 99203 to show that the E/M was a significant and separate service from the fracture care (25630 has a 90-day global).

No separate E/M: An established patient reports to the orthopedist for scheduled repair of their left wrist. Notes indicate that the orthopedist discussed the surgery, treatment, and course of recovery before performing the fix. They then perform closed treatment of a single carpal bone without mention of manipulation.

On this claim, the E/M is part of the work units for the wrist repair. So, you’d only report 25630-LT for this patient.

Know CPT^® Descriptors, Tx Terms

It is vital that a coder dealing with fractures knows the descriptors for each fracture care code — and what each of the terms means. Without this knowledge, a coder can sink a fracture care claim, Kipreos explains.

The code descriptor “tells me how you treated [the fracture] and it’s not always the same,” she says. Indeed, some fracture care codes mention manipulation while others do not; the fracture could be treated with open or closed treatment; internal fixation might also be utilized. If you don’t know what these terms mean, and how they fit into the fracture care CPT^® codes, you’re losing a valuable resource you could use to file the cleanest claim possible.