Wiki Fracture care MDM

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Hello,

I'm having a difference of opinion with a colleague regarding whether a closed fracture goes from an acute uncomplicated injury to a self-limited or minor problem just because it is healing and doesn't need to have a cast replaced or braced. My colleague is stating that once the provider states it's healing and no immobilization is need that it "converts" from an injury to a self-limited problem.

To clarify, I am not stating that the visit should necessarily be a 99213 on the number/complexity of problems alone as there was not sufficient supporting information in the data or risk to support the 99213; however I feel the incorrect credit is being given under the number and complexity of problems addressed section. I am wanting to clarify as there are occasions where my providers will state the fracture is healing, instruct the patient/parent to leave a brace on a little longer for additional support to the healing fracture area and then instruct them that they can remove it within 1-2 weeks or wear only during the day/activities, etc. - my colleague states it can still be counted as an acute uncomplicated injury in these situations simply because we are instructing them to use the brace a little longer even though the site is healing and we're not following up - but if we don't instruct continued use of the brace it suddenly becomes a self-limited problem - to me it's still an injury. Also, depending on the fracture site even though bracing is d/c'd that we may continue to follow for any growth plate healing issues/complications.

Here's one of the scenarios we're disagreeing on: We're a pediatric ortho practice , our PA sees a patient for a closed physeal fracture of the lower end of the radius - 1st visit on 6/28/2022 and had 3 follow-up visits (including the final one in question here) and up until this last visit the patient continued to complain of tenderness over the fracture site and went from casting to brace and on this last visit released from needing either. The provider did not bill fracture care global but opted for itemized billing. The PA states in her assessment on this last visit that "The fracture has continued to heal and to remodel. Is difficult to see the fracture line. He is able to put his full weight on it was right wrist. He does have full symmetric range of motion. His fracture does not involve the growth plate. He will therefore follow-up in the clinic on an as-needed basis."

I am not able to find anything that supports that an injury "converts" to a self-limited problem just because we're not doing casting/bracing any longer. To me the condition was an injury and per the AMA guidance an acute, uncomplicate injury is "Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain." So to me it reads that treatment may not necessarily required but is taken into consideration and on this last visit it was deemed by the PA as not needed as the fx site tenderness had resolved since last visit - but that doesn't mean that the fracture "went away" it's still healing, just not requiring mobilization.

Your thoughts/opinions would be greatly appreciated!
 
I don't know that there is a definitive "every time it's this" type answer for this. I think it depends on the documentation and each individual encounter for the patient. You probably didn't want to hear that but there is no black and white 100% for any of this. I am also assuming non-op fracture care (global) was not initiated for any these patients (I see you said itemized above) at the first visit because this question would not aply if that was the case.

Depending on the documentation you wouldn't necessarily need the first MDM element of # & complexity of problems to meet a level with 2/3 elements of MDM required. It's always going to go back to the documentation and definitions. In my thinking, I don't see how an inury that started out as an acute fracture (whether or not it was treated closed, perc or open) "changes" into self-limited or minor during the healing phase either.
Think of it this way. What ICD-10 are you using? You're still using the fracture S diagnosis with the appropriate last character which should follow the patient throughout the treatment for the fracture. So, in that case, it's still an acute injury even though it might have a "D" at the end.

I think it's also helpful to look at the entire visit in this case and not get bogged down in the one single element. In your example, if the patient is on their final follow up and is being told to come back PRN, the brace is off, they are full weight bearing, full ROM, growth plate was not involved, is told to follow up PRN, does that constitute a 213 or 212 "usually"? I would argue a level 2. Did they do XRays, talk to the parent, any OTC meds, etc? Was it one of the "yup looks good cya later!" type ortho visits?

I don't think the use of the brace or not is really a good determining factor alone.

Not that you should use it to code, sometimes I level the E/M using the "old" way just to see what it comes out as.

Some references just to read: https://namas.co/acute-uncomplicated-vs-complicated-illness-or-injury/
Old but discussion: https://www.aapc.com/discuss/thread...on-problem-complexities-diagnosis-mdm.186373/
 
amyjph said:
I don't know that there is a definitive "every time it's this" type answer for this. I think it depends on the documentation and each individual encounter for the patient. You probably didn't want to hear that but there is no black and white 100% for any of this. I am also assuming non-op fracture care (global) was not initiated for any these patients (I see you said itemized above) at the first visit because this question would not aply if that was the case.

Depending on the documentation you wouldn't necessarily need the first MDM element of # & complexity of problems to meet a level with 2/3 elements of MDM required. It's always going to go back to the documentation and definitions. In my thinking, I don't see how an inury that started out as an acute fracture (whether or not it was treated closed, perc or open) "changes" into self-limited or minor during the healing phase either.
Think of it this way. What ICD-10 are you using? You're still using the fracture S diagnosis with the appropriate last character which should follow the patient throughout the treatment for the fracture. So, in that case, it's still an acute injury even though it might have a "D" at the end.

I think it's also helpful to look at the entire visit in this case and not get bogged down in the one single element. In your example, if the patient is on their final follow up and is being told to come back PRN, the brace is off, they are full weight bearing, full ROM, growth plate was not involved, is told to follow up PRN, does that constitute a 213 or 212 "usually"? I would argue a level 2. Did they do XRays, talk to the parent, any OTC meds, etc? Was it one of the "yup looks good cya later!" type ortho visits?

I don't think the use of the brace or not is really a good determining factor alone.

Not that you should use it to code, sometimes I level the E/M using the "old" way just to see what it comes out as.

Some references just to read: https://namas.co/acute-uncomplicated-vs-complicated-illness-or-injury/
Old but discussion: https://www.aapc.com/discuss/thread...on-problem-complexities-diagnosis-mdm.186373/
Click to expand...
Thank you Amy for your input :) I completely agree much of what I see in ortho is not an "every time" and that's been difficult to explain to the providers as well as the coding team.

I did agree in this case with the level 2 as the data and risk both ruled out a level 3 and agreed on the S code with final character D as routine healing fx.

My concern was primarily the thought process in regards to the data section in a healed fracture mysteriously becoming a self-limited problem just because they are not seeing them back. I go case-by-case with my reviews and usually the data and risk will default the charge to the level 2; however sometimes I do have the occasional case that hits that "gray area" of possibly a level 3 and it is rare. However I feel this opinion regarding the "switch" in the data portion is not accurate. Because we do have a large majority that are in the younger age range and can't really tell you much other than "it hurts or doesn't hurt" or show you where, we do have the independent historian (parent providing add'l info as to their observation of the child's reaction to pain, guarding, etc at home), they almost always get a final x-ray to confirm callous formation/bone healing in order to make the decision to d/c the casting/bracing or if sufficient to allow parent/patient to d/c after a period.

Hopefully this is a better scenario that I see and received the same response on: Patient not under fracture care global age 3 and like the patient above may have only 1-2 maybe 3 follow-ups depending on the location/if involves growth plate. The patient state "no" to pain on the exam in the office; however mother adds that the patient is continuing to guard and occasionally acts as if tender. An x-ray is obtained to ensure that the fx site is still healing, and the PA is making the decision to continuing that bracing and instructing them it's okay to d/c within 1-2 weeks to ensure that the fx healing is sufficient and/or the patient is no longer experiencing tenderness/mild pain that may indicate continued an issue with healing taking place.

My colleague was stating that on any fx that the provider stated was healing and not following up (they always instruct if experiences any issues such as tenderness/pain/numbness to return) automatically "became" a self-limited" problem and using the portion of the AMA statement regarding acute uncomplicated injury "which treatment is considered" to mean that if the provider is not seeing them back to d/c the brace, then we could no longer consider it an injury - strange thing is though still agrees with the dx code being the S code with final character D. She also notes that this alone is the reason (no mention of reviewing the data/risk) she is deeming the visit a level 2 every time. I take that "considered" part by the AMA definition that there was a thought process that the provider went through in determining if additional treatment was needed or not. Depending on the child's symptoms and the x-rays, our providers are making that determination even if it ends up being deemed their "last" visit at the end.

My end point to all of this is that I'm trying to educate/empower my providers to choose the correct E/M level as the group that does our coding does not review 100% and I want those that are not reviewed to go out as accurately as possible. I don't feel that we are doing justice in telling them that just because you're not seeing them again that the data portion goes from acute, uncomplicate injury to a self-limited condition - especially on those that hit that "gray" area when you include the x-ray(s) and independent historian.
 
I agree with you, "telling them that just because you're not seeing them again that the data portion goes from acute, uncomplicate injury to a self-limited condition" is not totally accurate.
I don't agree with this either: "on any fx that the provider stated was healing and not following up (they always instruct if experiences any issues such as tenderness/pain/numbness to return) automatically "became" a self-limited" problem and using the portion of the AMA statement regarding acute uncomplicated injury "which treatment is considered" to mean that if the provider is not seeing them back to d/c the brace, then we could no longer consider it an injury - strange thing is though still agrees with the dx code being the S code with final character D. She also notes that this alone is the reason (no mention of reviewing the data/risk) she is deeming the visit a level 2 every time."

What is her supporting documentation for doing this? What is the justification? Is there concrete guidance from a reputable source? Most probably are level 2 but you can't just generalize it for every single one. If you are doing selective editing though, the 2s probably aren't going to be your problem. You could also consider the time. Are they spending more than 10-19 minutes on these patients? If not, it's probably not a 3.

What would a medical provider say to this? Is an acute fracture minor?... also the word "problem" versus "injury" in the definitions.

It's tough educating providers and a lot of times they want a black/white answer which makes it hard. Sounds like you are auditing and/or provider education only?
 
amyjph said:
I agree with you, "telling them that just because you're not seeing them again that the data portion goes from acute, uncomplicate injury to a self-limited condition" is not totally accurate.
I don't agree with this either: "on any fx that the provider stated was healing and not following up (they always instruct if experiences any issues such as tenderness/pain/numbness to return) automatically "became" a self-limited" problem and using the portion of the AMA statement regarding acute uncomplicated injury "which treatment is considered" to mean that if the provider is not seeing them back to d/c the brace, then we could no longer consider it an injury - strange thing is though still agrees with the dx code being the S code with final character D. She also notes that this alone is the reason (no mention of reviewing the data/risk) she is deeming the visit a level 2 every time."

What is her supporting documentation for doing this? What is the justification? Is there concrete guidance from a reputable source? Most probably are level 2 but you can't just generalize it for every single one. If you are doing selective editing though, the 2s probably aren't going to be your problem. You could also consider the time. Are they spending more than 10-19 minutes on these patients? If not, it's probably not a 3.

What would a medical provider say to this? Is an acute fracture minor?... also the word "problem" versus "injury" in the definitions.

It's tough educating providers and a lot of times they want a black/white answer which makes it hard. Sounds like you are auditing and/or provider education only?
Click to expand...
My primary job is provider education; however I use cases that I audit for each provider to make it more personalized education for them in hopes that they learn from it and do better going forward. I also receive cases from the coding team that they did not agree with the providers coding - I've found them to be largely accurate in their review; however have had to do some occasional sharing of information with their educator since we are employed by different entities so I don't directly educate the coders. Interestingly the coding team is on the same "page" I am in regards to the condition staying an acute, uncomplicated injury under data.

The only supporting information she gives each time I ask is that small snippet from the AMA definition which to me does not support so I think there is some difference of interpretation of that statement. I did some research prior to posting here to see if I might be missing something, but can't locate anything. That's why I was curious as to how others viewed this.

If the patient had an accident that led to the fracture, the providers do state it as an injury in their notes. They are pretty good in stating the status of the fracture and the cause. Because we are also a pediatric specialty ortho clinic we do have some osteogenesis imperfecta patients whose fractures are not necessary due to an injury but their disease. and they clearly state if this is an associated diagnosis/cause of fracture. Of course this patient population is totally different from our usual injury patients. We also have the occasional fracture due to bone met/lesion patient referred from our hem/onc division.

Just as an fyi to anyone who may be reading:
Osteogenesis imperfecta (OI) is a genetic or heritable disease in which bones fracture (break) easily, often with no obvious cause or minimal injury. OI is also known as brittle bone disease, and the symptoms can range from mild with only a few fractures to severe with many medical complications.
 
It's defintely differences in interpretation from what you describe. At the end of the day, does the coder get dinged for incorrect levels? Is the E/M coming out correctly and are they meeting the accuracy requirement? I guess I would pick and choose battles on this one. I don't think you're missing anything, I don't know of anything concrete like that. I would be more concerned if they were dropping a level 4 or 5 to a 2 or appending 25s inappropriately, more "red-flaggish" things. Is the provider coming back questioning why all of their 3's are being dropped to a 2, etc? Do they code every visit as a 5 and then someone has to audit every one?

Oh yeah, CA & OI is a totally different ballgame.

I think the grey area astuff and interpretation situations are what makes it fun.
 
Just wanted to jump in and say that I agree with both of you.

The grey areas keep things interesting and keep us in business.
 
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