Orthopedic Coding Alert

Don’t miss this 2016 Medicare guidance for global fracture treatments.

Miscoding when your surgeon in the ED provides multiple fracture repairs in the same session can mean you’re missing out on deserved payment. Read on for advice on how to appropriately list fracture services, beginning with the highest value code.

Tip 1: Capture All Services

You should list all fracture repair services that your surgeon provides to keep from omitting work units for any fracture that your surgeon is treating.

Example: You may read that for a patient who presented to the ED with a swollen foot after a road traffic accident, your clinician obtained a history, did a detailed clinical examination and diagnosed fractures in the left talus and calcaneus. Both the fractures were closed fractures and your surgeon did manipulation to treat the calcaneus fracture. In this case, you will report the E/M and the closed treatment of both fractures. In addition, you also append appropriate modifiers.

For the closed treatment of a calcaneal fracture, including the manipulation that your surgeon does, you report 28405 (Closed treatment of calcaneal fracture; with manipulation) – LT (Left side). For the repair of the talus fracture, you report code 28430 (Closed treatment of talus fracture; without manipulation) - LT. However, you cannot report both.

Best bet: Medicare allows only one global fracture treatment code to be reported in this scenario. From Medicare’s National Correct Coding Initiative 2016: “If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT^® code may be reported.”

Tip 2: Bill the Appropriate E/M

For E/M, you turn to 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...). You bill the appropriate level of E/M based upon whether the patient was admitted or simply seen in the ER. In general, you will not bill this as a consult, even if the health plan still allowed for a consult as requests to see patients with a known fracture from the ED is a transfer or care and not a request for an opinion.

You append modifier 57 (Decision for surgery) to 99283 to show that the surgeon decided on surgical treatment based on the E/M provided. Your physician would need to add modifier 57 to the E/M visit to report the decision for surgery.

Tip 3: Pick Up the Right Code for Modifier 51

You append modifier 51 (Multiple procedures) to code 28430 to show that the two repairs were separate procedures. Where you append the modifier 51 is going to make a difference in your payment.

In the example above, you append modifier 51 to 28430 to earn your deserved payment as the payer will pay a modifier 51-appended code at 50 percent its total value. This will need you to revisit the RVUs before you can append the modifier 51 in your claim. Most insurance carriers will determine the highest paying RVU procedure for 100 percent of the allowable fee schedule, and deduct secondary procedure payments accordingly.

However, you may like to check with your payer. Some insurance carriers prefer that you do not use modifier 51 as they determine the primary procedure, experts say. Using the modifier 51 pre-determines the primary and secondary procedures but this may not be the highest paying procedure in all cases, i.e. you may have pre-contracted with a carrier with certain procedures values.

Pay attention to the sequence in which you report the codes for the multiple fracture repair services. “The bottom line here is you must always sequence your highest valued CPT^® code first on the claim form or you will cost yourself reimbursement dollars,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. “If your reimbursement rate is based on RVUs, sequence the highest RVU valued code first. If your reimbursement is not based on RVUs, sequence the highest paying code first.”