Orthopedic Coding Alert

"Question: I performed a combination of open reduction with internal fixation (ORIF) and closed treatment fracture care on a patient who suffered a crush injury. How should I code the following?

ORIF open comminuted fracture distal phalanx left hallux

ORIF dislocated PIPJ second digit left foot

ORIF displaced third metatarsal fracture

Closed treatment of second, fourth and fifth metatarsal fractures.

The patient had extensive workup in the emergency department (ED) the same day, and we reported an ED visit with modifier -57 (decision for surgery).

Kansas Subscriber

Answer: First, identify everything that was done in the ED and operating room, what procedures are bundled with other codes, and what can be billed separately. Your call to the ED can certainly be reported using a code in the 99281-99285 range with modifier -57 appended.

Your fracture treatment codes should be as follows:

ORIF of the left hallux distal phalanx 28505 (open treatment of fracture great toe, phalanx or phalanges, with or without internal or external fixation)

ORIF dislocation proximal interphalangeal (PIP) joint, left second toe 28675 (open treatment of interphalangeal joint dislocation, with or without internal or external fixation)

ORIF displaced third metatarsal fracture 28485 (open treatment of metatarsal fracture, with or without internal or external fixation, each)

Closed treatment of second, fourth and fifth metatarsal fractures 28470 (closed treatment of metatarsal fracture; without manipulation, each). Because this code description contains the word each, you may report it as a single line item with 3 units of service. You may want to append modifier -59 (distinct procedural service), because 28470 will most likely be bundled into 28485 by the carrier.

For the three ORIF codes you reported, list the procedure with the highest relative value first and append modifier -51 (multiple procedures) to the two lesser procedures. A complicated repair such as this will require thorough documentation with the claim. Be sure the operative note fully describes the extent and nature of the injuries."