Orthopedic Coding Alert

Patient could suffer from an open or closed fracture.

When a patient reports to the surgeon with a fractured forearm, you risk a lot if you aren’t paying attention to the notes from the get-go.

Why? Just in the wrist fracture section of CPT^®, there are a dizzying array of factors to consider when choosing the proper repair code: for example, anatomy, type of fracture, and exactly how many bones were fractured are a few of the vital components of wrist fracture coding.

And that’s not even close to all the info on coding all wrist fractures. This month, we’ll break down how to code radial and/or ulnar shaft fractures with help from one expert coder and one practicing physician. Check out their thoughts on these type of wrist fractures.

Incision Means Fix Is Open

When you are breaking down radial and ulnar shaft fracture codes, you’ll notice that you need to know if the treatment of the injury is open or closed.

“Closed treatment is without any incision required to treat the fracture, even if fracture is considered ‘open’ due to a wound that was caused by the injury, which exposed the bone to the outside environment/air,” says Jeff Weintraub, MD, MBA, FAAEM, practicing emergency physician and business manager for the emergency physicians at Norwalk Hospital in Norwalk, Connecticut. Weintraub is also a fellow of American Academy of Emergency Medicine (AAEM).

There’s a baker’s dozen of CPT^® codes to choose from in the radial/ulnar shaft fracture repair section, starting with 25500 (Closed treatment of radial shaft fracture; without manipulation) and ending at 25575 (Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna).

Caveat: Don’t confuse open treatment with open fracture. For open fracture treatment codes, the surgeon treats the injury using incision, either at the fracture site or remote from the fracture site to insert an intermedullary (IM) rod or nail — so the opening is created by the surgeon. Conversely, open fracture “means the fracture caused a break in the skin, which could be just a puncture wound or an exposed bone,” explains Denise Paige, CPC, COSC, at PIH Health in Whittier, California.

Can You Code This Clinical Scenario?

Consider this detailed clinical example from Paige, and see if you can code the encounter before reading on:

A 13-year-old patient sustained an injury to his right forearm from a fall while riding a skateboard. The patient had immediate pain and deformity to his right forearm. The patient presented to the emergency department (ED); initial X-rays confirmed displaced fractures of both bones of the right forearm, and the ED provider applied a splint and advised the patient to seek further care with an orthopedic surgeon. The orthopedic surgeon reviewed the X-rays, provided a hematoma block to the fracture area, and performed a closed reduction of the radius and ulnar shaft fractures followed by additional X-rays to confirm the reduction. The orthopedic surgeon then applied a long-arm cast.

Here’s the Proper Codes

Paige says you should report the following codes for this encounter:

CPT^® codes/modifiers

• 25565 (Closed treatment of radial and ulnar shaft fractures; with manipulation) for the fracture treatment.
• Modifier RT (Right side) appended to 25565 to indicate laterality, if the payer requires it.
• 73090 (Radiologic examination; forearm, 2 views) for the X-ray.
• Modifier RT (Right side) appended to 73090 to indicate laterality, if the payer requires it.
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) for the evaluation and management (E/M) service.
• Modifier 57 (Decision for surgery) appended to 99203 to show that the surgeon decided on surgery after the E/M.