Pediatric Coding Alert

Report separate E/M services with modifier -25 when using global fracture-care code

When the pediatrician treats a fracture in the office, you can either report a global fracture-care code or report each service separately; the choice you make depends on the extent of the physician's services, coding experts say.

Fracture Approaches Vary by Practice

While most fractures are referred to an orthopedist, some pediatricians treat certain fractures in their offices. Just what each pediatrics office treats is entirely up to the physicians and staff.

"Our pediatricians will treat clavicle, finger and toe fractures" because they're usually pretty basic procedures, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.

"I've heard everything from 'It's not appropriate for us to code for fracture care' to 'We only code for fracture care if there's manipulation' to 'We code for everything' " when a patient reports to the pediatrician's office with a minor fracture, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla.

What Are My Options?

We will examine how to report a global fracture-care code and how to report each service separately using the scenario below.

Scenario: A 5-year-old established patient reports to the office without an appointment with pain, swelling and tenderness of the left wrist and forearm after falling off a seesaw. The pediatrician takes two x-rays of the forearm and finds a buckle fracture of the wrist, which he stabilizes with a splint before sending the child home.
 
Option 1: Report Fracture-Care Code

The easiest way to report the child's visit is to use one of the fracture-care codes. In this case, report 25600 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation). If the pediatrician performed the x-rays (as he did in the above example), report CPT 73090 (Radiologic examination; forearm, twi views.). X-rays determine the patient's condition and the course of care, so they are never included in global packages. You can also report any follow-up X-rays separately.

The global period for 25600 (Closed treatment of distal radial fracture ...) is 90 days and encompasses any immediate care related to the fracture, including dictating procedural notes, counseling the family, and speaking with other physicians about the patient, according to CPT 2004.

Warning: Code 25600 bundles in supplies and any follow-up care related to the procedure.
 
"If you do code for fracture care, that includes casting and splinting as well, so you cannot report those separately," Marsh says.

Use Modifier -25 for Separate E/M

During initial fracture treatment, report a separate E/M service when the doctor checks for some other trauma. In the previous example, if the pediatrician checked for head injuries in addition to casting the fractured wrist, you can report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. Modifier -25 lets the payer know that the E/M service was unrelated to the fracture treatment. An additional E/M service is almost always performed when a physician treats a fracture, especially when that physician is a pediatrician.

"Anytime you have an injured kid in the office, you're going to have to get to the point of 'How did this happen?' " Jackson says, leading to the E/M service.

Option 2: Report Each Service Separately

If your office would rather itemize each encounter with the patient, you can report the appropriate-level E/M service for the initial visit and separately code for casting and splinting, as well as for all subsequent E/M services related to the procedure. When reporting each service separately for fracture care, follow these steps:

First step: Report 99213 for the initial visit and fracture repair.

Second step: Report A4570 (Splint) for the splint, but do not report any dressings separately. ("Dressings applied by a physician are included as part of the professional service," according to HCPCS Level II.) Do not report splint application (29125, Application of short arm splint [forearm to hand]; static), which is bundled into the E/M service. Also include the x-ray code 73090.

"Items such as Ace bandages, slings and cast shoes are not considered straps and should be included when considering the level of E/M service," Marsh says.

Not all private carriers will pay for crutches and cast supplies, and some Medicare local medical review policies  don't even assign relative value units to the items; report them anyway, especially if you don't know the carrier's policy.

Creative option: Circumvent the crutches-coding conundrum by keeping a couple sets of "loaner" crutches on hand. Jackson says her office lets patients keep the crutches at no cost for as long as they need them -- if they return them in good condition.

Third step: Don't forget to report any typical postoperative follow-up care if you do not use the global fracture-care codes. If the doctor examines the child's wrist three weeks later, decides it has healed sufficiently and removes the cast, report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, straightforward medical decision-making).