Part B Insider (Multispecialty) Coding Alert

Published on Sat May 19, 2007 PDF

Don't attract carrier scrutiny with the wrong diagnosis code

Myth: A patient with a bone fracture still has the fracture until it's healed. So you should keep using the fracture-care code on your claims for every visit after your doctor sets the fracture.

Reality: You should use the fracture diagnosis only once. For every visit after the initial fracture care, you should use a post-fracture diagnosis from the V54.xx series.  

-The patient shouldn't still have the fracture, but should be in the process of healing,- explains Susan Posten, coder at the Houston Center for Spinal Reconstruction and Disc Replacement. Many coders will try to claim that the patient still has the fracture until it's fully healed, but this is incorrect, Posten adds.

Warning: Using the incorrect diagnosis code for aftercare could delay your payments, or lead to audits down the line, experts warn.

You should only use the pathologic fractures (733.1x) or traumatic fracture codes 800-829, when the fracture is newly diagnosed, according to the ICD-9 Official Guidelines for Coding and Reporting, effective Nov. 15, 2006. You can also use those acute or pathologic fracture codes when the patient is receiving active treatment for the fracture, notes Pat Strubberg with Patients First Health Care in Washington, MO.

-Active treatment- can include surgical treatment, an Emergency Department encounter or an evaluation & management by a new physician, Strubberg adds.
But for routine follow-up visits, you should use the V54.xx codes. Routine follow-up care includes -cast change or removal, removal  of external fixation device, medication adjustment, and follow-up  visits following fracture treatment,- says Strubberg.

Don-t list the fracture code as secondary, Posten says. The V54.xx series is appropriate on its own.

If the patient has a complication, such as malunion or nonunion of the fracture, you should use the appropriate codes, says Strubberg.

Once the physician says the fracture is healed, you should use a -healed fracture- diagnosis (V67.4).

Note: Medicare carriers, and most other payors, accept -V- codes. But you should check to see if your insurance plans have their own fracture-care policies, Strubberg adds.