Orthopedic Coding Alert

Claims for patients that suffer humeral shaft fractures can be difficult for coders to deal with. They have to identify the type of fracture as well as the type of treatment to nail the proper code. Further, they have to make sure that the surgery is coded as open or closed.

Getting any of this info wrong could have a major impact on both patient care and your practice’s bottom line. If you educate yourself on how to use the humeral shaft fracture codes now, you’ll be less likely to make a mistake when a claim crosses your desk.

Check out what two experts had to say about coding humeral shaft fractures right the first time.

Check Out These Codes

There are four codes for humeral shaft fracture repair:

• 24500 (Closed treatment of humeral shaft fracture; without manipulation)
• 24505 (… with manipulation, with or without skeletal traction)
• 24515 (Open treatment of humeral shaft fracture with plate/screws, with or without cerclage)
• 24516 (Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws)

It might seem like a pretty straightforward code set, but the devil’s in the details; in order to assign one of the codes correctly, you’ll need to know:

• The difference between open and closed treatment.
• The definition of manipulation, for coding purposes.
• How the surgeon might use intermedullary implants/ screws.

Read on for a rundown of each of these three components.

Know Open/Closed Differences

It would really be impossible to choose a humeral shaft fracture fix code unless you know whether the surgeon performed open or closed treatment. So you’ll need to know what constitutes each treatment.

According to Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey, “Closed treatment without manipulation would consist of placing the patient in a coaptation splint or sling.”

Often, closed reduction of humeral shaft fracture consists of two main maneuvers: first the shoulder is forced in abduction with the scapula stabilized to reduce the varus displacement of the humeral head, and then the application of a posteriorly directed force to the arm to reduce the medial displacement of the humeral shaft and the internal rotation of the head,” Stout explains.

This differs from open reduction, which is “common for open fractures, pathologic fractures, oblique and transverse fractures, fractures with intraarticular extension, and fractures with associated vascular or neural injury,” says Stout.

There really isn’t a rule book for when surgeons use open treatment versus closed; it’s up to the surgeon’s discretion and the patient’s individual needs. “There could be all sorts of reasons the surgeon might decide an open reduction would be appropriate and typically this is not something an insurer would question. It’s up to the surgeon,” according to Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Bucknam says some reasons surgeons opt for open treatment include:

• The bone is severely displaced or damaged in such a way that screws and plates are needed to reconstruct the fracture site.
• The fracture is an open fracture and the skin above the fracture site is already severely injured (or the bone is sticking through the skin) and the bone is repaired at the same time other injuries are repaired.
• The fracture is not healing appropriately and needs internal fixation.
• The patient has a medical reason that limits his or her ability wear a cast (e.g., an autistic person who might hurt himself or others with a cast; or a person with a skin problem that does not allow a cast to be worn for four to six weeks).
• The patient has a social situation that does not allow him or her to wear a cast. This might include an individual with multiple fractures who might have problems at school if they were wearing a cast.

Know These Manipulation Fix Terms

When a provider performs a humeral shaft fracture repair, you’ll have to decide whether or not they used manipulation, as it affects code choice.

Definition: “Manipulation is the process of putting the bones back in alignment when closed treatment is performed. The physician should clearly document that the bones were put back in place as part of his treatment documentation. If there is no manipulation the patient may only have a casting or sling or strapping but if there is manipulation there should be documentation that there was manual realignment of the bones,” explains Bucknam.

“However, if there is no documentation of manipulation the coder may suspect that manipulation was done if the X-ray indicates that the bones are out of alignment or if the patient was given some sort of anesthesia during the fracture treatment. Coders should query the physician and ask him to add documentation of the manipulation if there are reasons to think the bones were not in alignment and would need manipulation to heal correctly,” explains Bucknam.

Use 24516 When Surgeon Uses Screws/Implants

The 24516 code specifies insertion of intermedullary implant (such as a rod) or screws for open humeral shaft fracture repairs — often abbreviated as IMM nailing. According to Stout, “IMM nailing is common for segmental fractures, pathologic fractures, and in patients with severe osteoporotic bone.”

Bucknam says you won’t have many chances to use 24516, but you should know the code in case you get that outlier patient. “This is actually done fairly, rarely but would be specifically helpful for a patient whose bone needs to not only heal but also be reinforced. These patients may have bone disease (like osteoporosis). Patients with an intermedullary implant probably have a stress fracture,” explains Bucknam.

Check for Separately Codeable Services

Every patient is different, so there are no codeable services that automatically occur along with a humeral shaft fracture repair. There are, however, instances of patients receiving separately reportable services surrounding (or during) these surgeries.

“Patients who undergo open surgical repair of the fracture may have other associated injuries to nerves or muscle,” explains Stout. “Open fracture debridement and repair of injuries to nerves, tendons, or muscle would be separately reportable.”

Be on the lookout for these services, but be sure to check your contracts to make sure they aren’t bundled into the fracture fix codes.

Also, you might have the opportunity to report a separate evaluation and management (E/M) service if you can prove that it was significant and separate from the normal preoperative E/M work included in the fracture care code. Remember to append modifier 57 (Decision for surgery) to any separate E/M service that precedes a humeral shaft fracture repair.

Also: Be on the lookout for these potentially separately reportable services — but be sure to check with your payer if you’re unsure whether they pay separately for them. “Although casts, slings, and other bandages are bundled into the fracture care, casting supplies can be separately billed. Radiology studies can be billed separately and can also be billed separately when the patient comes in for follow up in the global period. Also, if the cast needs to be changed or replaced for any reason during the global period, the new cast can be separately billed.”