Wiki Thumb Fracture

alk@APS

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Need help again - a patient was seen in office for thumb fracture and fracture code was charged, then doctor decides to do surgery and put in a pin so surgical code was charged. The original fracture code is being denied. There are no modifiers on either claim. Can both be billed or just bill the surgery? Thanks for any help
 
A little clarification is needed. Are these two separate dates? Of so how many days apart. What codes exactly were billed on each claim. What was the reason for the decision to insert a pin at the later time
 
Patient was seen in ER and then referred to office for thumb fracture. The first visit to the office he decides to do surgery the office visit was coded with a 26720 with a 59 modifier. He does the surgery and that is coded with a 25630. The surgery was paid the initial office visit with the fracture code is denied. How do you code for this type of scenario, should the initial visit be the pre surgical visit and not billed? I have several exapmles of this and I am trying to clean up old denied claims in an ortho office but I code for anesthesia and don't remember all the fracture rules. Thanks for any help
 
Let me be sure i understand. At the first office visit he decides the patient need surgery. That should have been an E/M only. (may need 57 modifier depending on DOS) Then the surgery occurs, and should be billed with the appropriate CPT.
HOWEVER---
I did notice your CPT's DON"T match. 26720 is for closed treatment of a prox or middle phalangeal fracture. 25630 is closed treatment of a carpal (not scaphoid) fracture.
It could be possible to treat a phalanx fracture in clinic, then a carpal bone in the OR. The clinic fracture care would be straight billed, then the surgical fx care would be appended with the 59 if appropriate. 25630 would be odd to do in the OR, though, since it is closed treatment without manipulation. I say pull the documentation on both encounters and see what you are really dealing with.
 
There were 2 coders working on this the first one charged the fraxture code 26720 and then a week later when the surgery was done the second one charged with a 25630. I am trying to go behind both of them and clean up unpaid accounts learning ortho guidelines as I go. He made the decision to do the surgery at the visit that is being coded with a 26720 so I think that should have been a no charge visit and part of the code 25630 for the surgery?
 
The 2 CPT codes are for different procedures on distinct bones. You should pull your documentation and verify this patient had 2 different fractures. If so, then he could have billed the office visit with the closed tx of a finger fx (26720) and treated the carpal bone fracture in the operating room. I question the code 25630 in the OR, though. More commonly seen is the 25635 or 25645. You really need to pull your clinic note and Op Report and verify what was broken, and how it was treated.
 
I have to agree, if the first visit was an evaluation to determine surgery then there should not be a fracture code, it is all dependent on what the documentation tells you. It sounds like the patient had two different fractures or then again maybe not.
 
Everything I am reading states thumb, he did a clsoed reduction with pin fixation in OR
 
Then i feel like 25630 may be the wrong code. Without reading the Operative report I really can not give much more advice. You are welcome to post a redacted Op Note here, or email me privately, and I will be glad to help you.
 
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