Orthopedic Coding Alert

Your sequencing matters to your bottom line.

Not paying attention to work units for all the fractures that your surgeon is treating can turn these procedures into a cash sink hole. The solution? Ensure you are paid the highest value code at the highest percent of payment and keep in mind that codes submitted beyond the first may then be reimbursed at half of their values. Follow our expert advice on sequencing.

Grasp Hierarchy Fundamentals

You’ll order your fracture codes using the RVU listing for the fracture codes. The services should be listed in order of RVU hierarchy on the claim form to avoid potential issues under reimbursement. Improper ordering can lead to a multiple procedure discount on a higher valued procedure if the highest valued procedure is listed in the secondary position, experts say.

Be Sure to Confirm With Your Payer

 Since payer policies vary, check with your payer to verify sequencing. In general, you should try to report these based upon the RVU value for the fracture management; however, Medicare and many other but not all health plans state that they pay based upon RVU, not based upon order in which the codes appear on the claim.

Examples Show You How

Example 1: If your surgeon is treating closed fractures in the left talus and calcaneus and does manipulation to treat the calcaneus fracture, you report codes 28405 (Closed treatment of calcaneal fracture; with manipulation)-LT and 28430 (Closed treatment of talus fracture; without manipulation)-LT.

You list the RVUs for the codes for the calcaneus (28405) and talus (28430) fractures. Code 28405 is worth about $404.23 (11.29 transitioned facility RVUs multiplied by the 2016 Medicare conversion rate of 35.8043). The 28430 code is worth about $243.11 (6.79 RVUs multiplied by 35.8043).

Since the payer will pay a modifier 51-appended code (28430) at 50 percent its total value, you see that your payment for 28430 will reduce by half, i.e. $121.56. On the other hand, if you report the reverse order in the example above, i.e. you append modifier 51 to 23405, you are certain to lose much more on your payment. Your payment will now fall by half of the 28405 value, i.e. by about $202.12.

So, the correct order of the claim will be 28405, 28430-51. This helps you to maximize payment.

Example 2: Suppose you report code 27506 (Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws) with RVU 38.56 and 25609 (Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments) with RVU 30.05. If listed in the correct order, your reimbursement would equal RVU 53.59.

If the treatment of the radius fracture was listed first on the claim and the multiple procedure discount was taken on the femoral fracture treatment service, your RVU’s would equal 49.33. Your loss in reimbursement would be 4.26 RVUs for the improperly ordered claim.

Severity of Injury Is Not a Good Guide

Another approach you may be adopting could be to list the procedures in order of the severity of injury. A good example is say a multiple trauma patient who has fracture of the left femoral shaft, closed trimalleolar fracture of the right ankle and right talus, distal radius, and an open supracondylar fracture of the right femur.

For instance, you may read that the fracture in the left femoral shaft was treated with IM nailing and you report code 27506 (RVU 38.56). You may also read that the ankle fracture was treated by ORIF including fixation of the posterior malleolus for which you report codes 27823 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip) (RVU 27.47) and 28445 (Open treatment of talus fracture, includes internal fixation, when performed) (RVU 30.60). For closed reduction of the fracture in distal radius, you report code 25605 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) (RVU 15.56). There is no documentation of debridement for the open fracture in the right femur, you report code 27511 (Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when performed) (RVU 28.74) for the open reduction and internal fixation that your surgeon does.

Technically the open fracture is the more severe injury and should be listed first; however, the RVUs for the supracondylar fracture are actually less than for the IM nailing of the femoral shaft. In general, you should bill this scenario in the following order which would be RVU based:  27506, 28445, 27511, 27823, and 25605.

The bottom line: “Always sequence your codes in the manner that maximizes your reimbursement,” 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. “You should always bill in order of decreasing RVUs. Severity is not something to be taken into consideration by coders,” says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C.