Wiki E/M leveling for fractures

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Frankiew

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Can anyone give me some guidance on how to calculate an E/M level for fractures? Example... nondisplaced nonangulated torus fracture of the distal radius. X-rays reviewed from another facility.
 
Frankiew said:
Can anyone give me some guidance on how to calculate an E/M level for fractures? Example... nondisplaced nonangulated torus fracture of the distal radius. X-rays reviewed from another facility.
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This grid from the AMA is a really helpful tool for walking through MDM:

For the buckle fracture:

  • Number/Complexity of Problems (Column 1): An acute, uncomplicated injury falls into Low.
  • Amount/Complexity of Data (Column 2): If the physician reviewed the film and documented an independent interpretation of the outside X-ray, that would count as Moderate.
  • Risk (Column 3): Unless there was patient-specific risk documented, management of a buckle fracture would typically fall under Minimal to Low risk for morbidity with further testing or treatment.

Because the overall MDM level is based on 2 of the 3 elements, this case supports a Low MDM - 99203/99213.

(Unless there’s additional patient-specific documentation that would raise one of the elements from what was outlined above.)
 
sls314 said:
This grid from the AMA is a really helpful tool for walking through MDM:

For the buckle fracture:

  • Number/Complexity of Problems (Column 1): An acute, uncomplicated injury falls into Low.
  • Amount/Complexity of Data (Column 2): If the physician reviewed the film and documented an independent interpretation of the outside X-ray, that would count as Moderate.
  • Risk (Column 3): Unless there was patient-specific risk documented, management of a buckle fracture would typically fall under Minimal to Low risk for morbidity with further testing or treatment.

Because the overall MDM level is based on 2 of the 3 elements, this case supports a Low MDM - 99203/99213.

(Unless there’s additional patient-specific documentation that would raise one of the elements from what was outlined above.)
Click to expand...
Thank you!
 
It depends. Did they come in already wearing velcro brace and it was a fairly simple visit for a child that maybe fell on the wrist, went to urgent care, carried in outside XR to an ortho hand/wrist doc and they left them in the brace and sent them on their way with PRN f/u and to use Ibuprofen or Tylenol? In your example if it was a child, let's say the parent gives hx, they tell them OTC meds and brace, review the outside film (no interp.), and they don't even set a f/u it's probably a 3.

However, we can't always say well, this fracture or that fracture will always be low/mod/high, etc. There's more to it than that.
Most of the time fractures are not acute, uncomplicated unless maybe they buddy tape a toe or something/nondisplaced, etc.

This is for the ED but has good examples from ACEP: https://www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines
 
The idea that the diagnosis code itself somehow plays into the E&M coding level is (1) exactly what the revised E&M guidelines were designed to prohibit and (2) being weaponized by AI-based tools used by insurers to downcode visits. You should not fall into the same trap or support this misconception.

Nondisplaced fractures, if untreated, may displace and require surgery. A nondisplaced fracture is not necessarily an "acute, uncomplicated injury".

Encourage your providers to provide context. We typically note that "this fracture, if left untreated or undertreated, could lead to significant morbidity or functional loss." That is, by definition, "acute complicated".

This only addresses the first column for MDM. The rest is based on amount of data analyzed (eg, a GP reading an XR report versus an orthopaedist reviewing and independently interpreting the images) and the risk of treatment (eg, splint/cast, vs PT/OT, vs medication management).
 
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