Orthopedic Coding Alert

Modifiers can be the key to payment

Do you know your Galeazzi fracture from your buckle fracture? Your Pott's from your Dupuytren? Unless you assign the correct diagnoses to these conditions, you could forfeit reimbursement.
 
Take a look at four frequently asked fracture care questions to check your coding know-how.

Fractures Don't Always Follow Time Limits

Question 1: A patient fractured his arm and went to the emergency department (ED) for treatment. The ED physician diagnosed the fracture and splinted it, and then told the patient to come to our office the next day for manipulation and casting. The patient waited a week before he finally came into our office. Can the orthopedist bill the fracture care code, or is it too late at that point to bill fracture care?
 
Answer: Regardless of the time that elapsed between the patient's ED visit and your physician's encounter, only the orthopedist can determine whether his treatment meets the CPT definition of fracture care. Fractures heal at different rates based on a number of factors, so the physician might think the fracture has healed enough that the patient requires little or no additional treatment. If that is the case, you should report an E/M code (99201-99215). If, however, the surgeon performs fracture care, he should bill the appropriate code.
 
For example: The ED physician diagnoses a patient with an ulnar shaft fracture, splints the fracture and refers her to the orthopedist. The patient comes to your office a week later, and the orthopedist performs closed treatment with manipulation. You should report 25535 (Closed treatment of ulnar shaft fracture; with manipulation).
 
"There is no 'standard' on fracture care time limits," says Mary J. Brown, CPC, CMA, coding specialist at OrthoWest PC in Omaha, Neb. "Some patients don't even come into the office for a fracture for 10 days because they are trying to live with it, thinking it is nothing serious."

Let Physician Choose Fracture Care Code Rules

Question 2: A patient presented with a hairline fracture, but the orthopedist didn't have to perform manipulation or casting because the fracture was so minor. Should we report fracture care, or should we just report an E/M code and x-ray code?
 
Answer: "It's up to the physician to bill this as fracture care or a la carte," says Denise Paige, CPC, coding manager at Beach Orthopaedic Associates in Long Beach, Calif., and president of the American Academy of Professional Coders' Long Beach chapter. According to the American Academy of Orthopaedic Surgeons' advice, either choice might be accurate, based on the physician's work and documentation.
 
"Personally, in my practice, unless the fracture requires a manipulative reduction, we choose to bill for the service separately, meaning no fracture care," Paige says. "If you bill a fracture care code, you open a 90-day global period and any subsequent office exams are not billable. But in this scenario, you can go either way." 
 
Reminder: Your patient may not understand that the fracture codes represent a "surgery," even though the orthopedist never made an incision. "It may help to explain your office policy when choosing to bill using the fracture care codes," Paige says.

Modifiers Separate Sites

Question 3: If a patient has two metacarpal fractures and a wrist fracture of the same hand, how should we modify these procedures for the maximum amount of reimbursement?
 
Answer: You should code the wrist fracture first because it represents the orthopedist's major service. For example, you might report 25680 (Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation). And you should add the appropriate site modifier (-LT for the left side and  -RT for the right side).
 
List the metacarpal fracture codes (such as 26600, Closed treatment of metacarpal fracture, single; without manipulation, each bone) on separate lines, with the appropriate modifiers. And you should append modifier -51 (Multiple procedures) to the metacarpal fracture and modifier -59 (Distinct procedural service) to the second metacarpal fracture so the insurer won't deny it as a duplicate charge. Therefore, your claim might appear as follows: