Orthopedic Coding Alert

Orthopedic coders sometimes use E codes (external causes of injury and poisoning) to enhance reimbursement for claims for fractures and other injuries. But commercial carriers often deny claims when E codes are used to supplement other diagnostic codes. The key to optimizing reimbursement with E codes after determining which carriers accept them is to use them correctly with the diagnosis code, to followup with the patient, and to clarify the documentation of the accident.

In the orthopedic setting, E codes are used when the patient has an injury or accident that is the result of environmental events or circumstances. They range from the common (E880.9, fall from other stairs or step) to the obscure (E847, accidents involving cable cars not running on rails) and describe virtually every accident in which an external factor was involved. In claims for injuries, E codes help answer the question, How did it happen? They inform the carrier with a short description of how an accident occurred.

Two Codes Are Usually Required

Using E codes to describe how an injury occurred is usually a two-part process. One code describes what the patient did he or she fell, got hit by a car, etc. A second code describes where the accident occurred in the patients home, at an amusement park, airport, bank, etc. These place of occurrence codes are in the E849 series, with a fourth digit required to specify location. Especially important for workers compensation claims, they help the carrier determine both circumstances and liability for an injury. Most workers compensation carriers insist on the use of E codes to explain how the injury occurred, the intent (whether accidental or intentional) and the place of incidence.

Likewise, E codes do not replace diagnostic codes; they simply better explain the circumstances of an injury, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. If a patient falls off their front porch and breaks their arm, there are three codes that apply, she says. Code 813.42 (other fractures of distal end of radius [alone]) describes the injury, and E882 (fall from or out of building or other structure) tells the carrier that the patient fell off a porch. The third code, E849.0 (place of occurrence; home), informs the carrier where the accident occurred. The three codes together describe the what, where and how of the accident, Callaway says.

E codes do not have a reimbursement factor; in other words, they will not impact the amount a practice is paid for treating an injury. They are the last code reported in a claim and are for information only. The codes are never to be reported in lieu of a diagnostic code to describe an injury; they simply help the carrier understand how the injury occurred.

Carrier Denials for Non-workers Comp Claims

For non-workers compensation claims, E codes are not a guarantee of reimbursement. Mona Klaker, CPC, is senior coder and reimbursement specialist for Valparaiso Orthopedic Clinic, a seven-surgeon clinic in Valparaiso, Ind. She experiences frequent carrier denials when submitting E codes for accidents that result in fractures and other orthopedic injuries. Our practice has had very little success using E codes, she says. Often, carriers will suspend payments for services based on the ICD-9 code until further information is received from the insured or participant.

Other coders report similar difficulties with E codes because many insurance companies require them to get accident information directly from the patient. When a provider submits a claim with an E code to one of these insurers, the claim gets an automated rejection for a mismatched diagnosis code, or it gets stalled in process. I have been told by several carriers that even if this information is provided by the practice, they still want the information from the insured, Klaker says.

But the flip side presents problems as well. Providers who require that the accident information come from the patient typically send the patient a form to describe the accident. And, as Klaker points out, if the patient does not give the correct information or if information is missing, it raises questions about the validity of the claim. Also, once the task of documenting the claim falls into the hands of the patient, the claim often gets delayed, according to Callaway. Once that letter goes to the patient requiring them to describe their accident, the claim is stalled and theres nothing you can do to expedite it, she says.

In such instances, phone calls to patients asking them to move things along may help. Sandra Hamrick, a biller and coder with Toledo Orthopaedic Surgeons Inc., a four-physician orthopedic/sports medicine practice in Toledo, Ohio, typically contacts the patient and reminds him or her to submit the completed form to the carrier. If we are not successful in getting the form turned around, we make the patient responsible for the bill, Hamrick says. That usually prompts him or her to call either our office or the insurance company to find out why he or she is being billed. When the patients realize they are being billed because they did not complete the required paperwork, it usually speeds the process along.

E Codes Boil Down to Carrier Rules

To determine whether E codes will prevent or create more denials, several of the coders contacted for this story called their main insurers to find out whether they accepted the codes. The results showed that each carrier has its own claim edit system some carriers accept them and others do not.

If an insurance company doesnt want E codes, Callaway says, theres not a whole lot you can do about it. However, she recommends finding out which companies will and wont accept the codes. Many insurers want to see E codes for accidents and injuries because it saves them the trouble of going through the patient for the same information that the codes can describe succinctly.

If the carrier leaves the option of using E codes up to the provider, Callaway recommends using them. If your receivables get tied up waiting for patients to respond with their accident forms, or you have the option of expediting the claim with E codes, then using the codes is worth the effort, she explains. Callaway recommends an internal audit of accident-related claims to determine how many could have been expedited by use of E codes. If your audit reveals that you can reduce the number of claims pending or denied by even as little as 25 percent, then I definitely encourage ortho coders to start using them.

Keep the Accident Report Simple

When documenting an accident for insurance purposes, keep the information as simple as possible. If the patient says he fell off the front porch of a house, report that code, Callaway says. If it turns out he fell off his neighbors house, thats for the insurance company to deal with. The mission is to report the information accurately, without giving so much detail that the claim gets tied up in liability and delays your reimbursement. In Callaways earlier example, for instance, if the accident occurred at a neighbors home, your patients insurance company may approach the homeowners insurance company and negotiate a settlement of the claim. But this negotiation is between the two insurers and need not involve the orthopedist who sets the fracture. By reporting the accurate but minimal information that the injury was the result of a fall from a front porch of a house, the provider is not being dishonest, but merely making every effort to get the claim paid without aggravation.

Ultimately, orthopedic coders may find that E codes are worth the additional coding to report accurately and to expedite payment. Callaway says that practices are wise to at least attempt using the E codes to see if there is a noticeable improvement (or downturn) to reimbursements. Try using them, she says. Test the waters, one insurer at a time. If you find that E codes are not effective, then dont worry about them. But before giving up on them completely, see if they positively impact your bottom line.

Note: Be sure to review the ICD-9 guidelines for reporting E codes, located at the beginning of the E code section (page 251) of ICD-9 2001.