Posts Tagged AAOS

Fractures 101: Let’s Cover the Basics

By Cynthia Everlith, BSHA, CPC, CMA

Fracture care may seem straightforward, but there are common misconceptions and confusion when it comes to the different types of fractures and how to bill for services. To set the record straight, here’s everything you wanted to know about fractures, but were afraid to ask.

What Is a Fracture? 

Many people believe a fracture is a “hairline break,” or a certain type of broken bone. That is not true: A fracture and a broken bone are the same thing.

What Are the Different Kinds of Fractures?

There are several types of fractures: transverse, oblique, spiral, angulated, displaced, and angulated, and displaced (see Figure 1).

How Many Types of Fractures Are There?

An exhaustive list of precise fracture types would fill a book. A few examples include the following:

Barton’s fracture: Fracture of the distal end of the radius into the wrist joint (ICD-9-CM 813.42 Other closed fractures of distal end of radius (alone)).

Fissure fracture: A crack extending from a surface into, but not through, a long bone.

Jefferson’s fracture: Fracture of the atlas (first cervical vertebra).

Lead pipe fracture: The bone cortex is slightly compressed and bulged on one side, with a slight crack on the other side of the bone.

Parry fracture/Monteggia’s fracture: Fracture of the proximal half of the shaft of the ulna, with dislocation of the head of the radius (ICD-9-CM 813.03 Closed Monteggia’s fracture).

Ping-pong fracture: A type of depressed skull fracture usually seen in young children, resembling the indentation that can be produced with the finger into a ping-pong ball; when elevated it resumes and retains its normal position.

Pott’s fracture: Fracture of the lower part of the fibula, with serious injury of the lower tibial articulation, usually including chipping of the medial malleolus, or rupture of the medial ligament.

Colles’ fracture: A fracture of the lower end of the radius, with the lower fragment displaced backward. If the lower fragment is displaced forward, it is a reverse Colles’ fracture (ICD-9-CM 813.41 Closed Colles’ fracture).

These are just a few fracture types; the list is extensive. To help with coding when reviewing fracture documentation, have a medical dictionary or other resource on hand to look up unfamiliar terms.

How Do You Fix Fractures? 

Generally, bones heal best when immobilized, so treatment often involves casting the broken bone (or fracture), and may require surgery to set the bone in place. Prior to casting or fixation, the broken bone(s) must be returned to its proper position. This is referred to as “reduction.”

“Closed” reduction is manipulation of a fracture without an incision. “Open” reduction refers to manipulation of a fracture after incision into the fracture site. When coding fractures, you will need to know the type of reduction used, as well as which body part is affected (leg, arm, finger, foot, etc.) and, in some instances, the precise location of the fracture (For instance, does the fracture affect the head or shaft of the femur?).

As an example, consider the X-ray images in Figure 2. Each describes a different type of fracture and fracture reduction.

The X-ray on the left reveals a fracture on the third or long finger proximal phalanx (816.01 Closed fracture of middle or proximal phalanx or phalanges of hand). This fracture is minimally displaced, and could be an example of a closed treatment of a phalangeal fracture (CPT® 26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) or closed treatment with manipulation (26725 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each), depending on what the provider documents.

On film A, the short arrow shows a displaced fracture of the index finger (816.01), while the long arrow shows multiple finger metacarpal fractures (815.03 Closed fracture of shaft of metacarpal bone(s)).

On Film B, the short arrow points to a percutaneous pin fixation (CPT® 26727 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each) and the long arrow points to an internal fixation with plates and screws (CPT® 26615 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone). There are also types of internal fixation for fractures, such as rods and spheres.

How Do You Bill Fracture Fees?

There are two common approaches when coding non-manipulative fracture care services. The American Academy of Orthopaedic Surgeons (AAOS) and the American Medical Association (AMA) support these two approaches. The AMA has published several articles in CPT® Assistant to reflect how these options work. The two options are:

  1. Fracture global fees
  2. Alternative method for fracture fees

The AAOS Guide to CPT® Coding for Orthopaedic Surgery definition of fracture global fees reporting method states:

“Fracture global fees may include the hospital or office encounter in some payment areas. In others, CMS allows you to code an E/M service with a -57 modifier [Decision for surgery] within the global period if the visit was the one in which the decision to perform the procedure was made. The initial cast or splint is applied, and all revisits, excluding radiographs that are obtained by the physician, should be included within a 90-day period from the time of the initial fracture. All recastings and or splinting are on an ‘encounter’ basis and are separately billed.”

AAOS defines the alternative method as such:

“Only when treatment of the fracture does not consist primarily of a ‘procedure’ (for example, closed treatment without manipulation), services may be itemized as if the problem were recognized as an office encounter. Examples include an undisplaced fracture of the fifth metatarsal; a fracture of the pelvis, undisplaced or minimally displaced; or a compression fracture of a vertebra. Office, hospital, and emergency department encounters are coded as appropriate, as are all injections, supplies, casts, splints or treatment program necessities.”

Be aware that this guidance is payer specific: When fracture care is performed in the office, the payer may want you to append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the evaluation and management (E/M) service.

Your practice must decide whether to bill for treatment of a fracture or to itemize, depending on your scenario.

Coding Example No. 1

Closed reduction without manipulation vs. E/M

If you report closed reduction w/o manipulation:

  • Cast/splint/strapping is included.
  • X-ray and supplies may be separately reported.

If you report an E/M service:

  • Cast/splint application, X-ray, and supplies all may be separately reported.

The closed reduction, if you report it, includes a 90-day global package. The first casting, splinting, and strapping are included in the procedure, along with all post-op visits. Global treatment excludes X-rays, durable medical equipment (DME), and any casting or splinting supplies, all of which must be reported separately. The global package means that you are not allowed to charge for the post-operative portion of the procedure. In simple terms, you cannot charge for an office visit until after the global period.

In such a case, proper coding would be:

  • Procedure: 26725
  • Do not code separately for cast or splint application.
  • Next visit: 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure
  • You cannot charge separately for related E/M services during the 90-day global period.
  • You may report casting and/or splinting supply charges according to documentation.

Coding Example No. 2

A patient comes into your office with a fractured clavicle. The fracture is not displaced and has good position. The patient is given a sling and told to follow up PRN (as needed). Can the office bill fracture care? Is this considered treatment if the patient is not to return?

Remember: When charging for a fracture care code (or any surgical procedure), there is a formula that includes preoperative, operative, and postoperative portions.

Physician reimbursement (approximate): 

  • 17 percent preoperative
  • 63 percent operative
  • 20 percent postoperative

In this example, there is no intent that the provider will follow up with the patient, which eliminates the postoperative portion of the formula. The argument could be made that billing the fracture treatment code would be incorrect. For instance, if an emergency department (ED) physician treats a fracture with no intent to follow up with the patient, it would be incorrect to bill a fracture care code. Rather, you would report an appropriate E/M service.

Let’s consider a different scenario using fracture codes and how the reimbursement varies using the formula.

Coding Example No. 3

A patient was injured on the slopes of Utah and lives in New Jersey. He has surgery in Utah and returns home, where he receives follow-up care. What happens to reimbursement?

Ideally, the surgeon in Utah should get 17 percent for the preoperative portion and 63 percent for the operative or surgical portion. If the surgeon knows that the patient is not staying for postop care, he should apply modifier 54 Surgical care only to the billed fracture care code. He or she should call (and provide written documentation to) the patient’s orthopedist in New Jersey to transfer care. The orthopedist accepting care should bill the same surgery code with modifier 55 Postoperative care. The accepting orthopedist would receive 20 percent or the postoperative fee.

In the real world, the billing is almost never as ideal as in our examples. What surgeon wants to give up 20 percent of his surgery fee? What physician wants 20 percent payment to treat someone else’s work? In working in orthopedics for 25 years, I have not seen this happen. What can one do if faced with this similar scenario?

You should make a call to the surgeon in Utah (or wherever the initial treatment occurred) and plead your case. If the surgeon has already filed a claim, but agrees to split the fee, a corrected claim would need to be filed. If there is no phone call placed, with no documentation stating the transfer, you cannot bill for the postoperative care.

Cynthia Everlith, BSHA, CPC, CMA, is practice administrator for Arizona Hand and Wrist Specialists, a division of OSNA, PLLC. She has more than 25 years of experience in orthopaedic coding and practice management, and 16 years with her current practice. She is actively involved in workers’ compensation legislation and has worked closely with the Industrial Commission of Arizona and the Arizona Medical Association in rules affecting physicians. She has presented nationally and locally. She is a past American Association of Orthopaedic Executives (AAOE) Board of Directors and past president of AAPC’s Grand Canyon Coders Phoenix chapter. She serves on the AAOE Communication Council and Technology Task Force, and is president of the Arizona AAOE Chapter.

October 1st, 2012

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Seek Specialty Opportunities and Overcome Their Challenges

The benefits of taking on a new specialty are worth the initial extra legwork.

By Pam Brooks, CPC

The trend toward comprehensive patient care will create a demand for many new multi-specialty practices. As practices expand, the need for specialty coders will, too. But these jobs won’t come without challenges. Even experienced coders can become overwhelmed when learning a new medical specialty, with all the unfamiliar procedures, terminology, and payer guidelines. With a fair amount of organized and careful front-end prep work, coders can overcome the obstacles of learning a new specialty and reap the rewards.

Review the Data and Do Your Homework

If your new medical specialist has recently worked in another practice setting or facility, you may be able to get a list of his or her coding activity over the past year. When a provider joins a new group, the accounting department usually has access to this historical data to determine the return on investment (ROI) they can expect based on past performance. This list can provide you with insight as to the kind of work your specialist will do at your site.

If possible, sort the list of CPT® codes from the most- to least-commonly performed procedures. This will give you an idea of the scope of the new provider’s practice, and where you’ll need to focus your efforts in terms of learning new coding guidelines. You should also review the list against the most up-to-date version of CPT® to make sure the codes are still current. Keep in mind, however, that any previous coding and billing should be viewed as “suspect.” That is not to say you should assume the provider was billing incorrectly or fraudulently; rather, only use this historical data as a guideline. After careful review, move forward. This will help to ensure your own correct coding.

It’s unlikely that diagnosis coding will be included in the financial data because physician coding and billing is not reimbursed based on diagnosis. It’s a good idea, however, to research the conditions and illnesses for the procedures you’ve identified and to learn about the related anatomy, pathophysiology, and typical treatment plans. Familiarizing yourself with common courses of treatment will enable you to recognize when your provider has gone over and above what is expected. If you come across unfamiliar terminology or concepts, look them up. This is an excellent way to learn about your new specialty or to refresh your memory.

Meet with Your Doctor

To better familiarize yourself with your new specialty, secure a time to meet with your new provider to learn about the types of services she provides. Ask if there are any videos or books you could review that would give you a visual perspective of her work. Alternatively, there are a fair amount of surgical procedures available on YouTube. Or, you can Google any of the procedures you are unfamiliar with.

To prevent billing errors, ask your provider what procedures she will perform in the office verses in an outpatient surgery or inpatient operating room setting.

If part of your responsibility is charge capture, you can also use this meeting to decide which services belong on an office fee ticket, and which services might need to be on billing cards or order sheets for work done in the facility setting. If your provider will be using an electronic health record to document her work, you can offer your expertise as a coder to become a part of the template development team by offering advice on documentation guidelines.

After you’ve gotten a pretty solid idea of your provider’s scope of practice and the procedures you can expect to see, start doing compliance research to support your correct coding. Access the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) to determine if any of the identified procedures or diagnostics will require you to bill globally or with modifier 26 Professional component. This is also where you can determine whether an assistant surgeon is allowed, what the global days are, and what the associated relative value units (RVUs) are.

Note: For more information about the Medicare Physician Fee Schedule (MPFS) database, see “Use the PFS RVF to Expand Your Coding Knowledge,” April 2011 Coding Edge, pages 42-44.

Know Specialty-specific Code Guidelines

To make sure you’ll recognize which codes cannot be bundled, run commonly-used codes through the National Correct Coding Initiative (NCCI) edits, and take the time to revisit the modifier lists and definitions to determine if any modifier use would be required in certain circumstances. You’ll want to make sure your chargemaster reports the appropriate fees associated with those modifiers that affect reimbursement, so you aren’t under- or overcharging.

If any unlisted codes show up as part of your new provider’s scope of practice, you will have to investigate the most appropriate comparable listed code. You should also review HCPCS Level II and Category III codes to make sure none of these are being overlooked regarding your new provider’s billable services, equipment, or new technology.

Visit the websites of both CMS and your local carrier to identify any national and local coverage determinations (LCD) related to the list of CPT® codes you’ve identified. It can be helpful to gather all of this information into either a notebook or on your desktop as a virtual procedures manual for later reference. Just remember to update it every year.

Expand Your References

Medicare isn’t your only payer, of course, so visit all of your payer websites or contact your provider representatives to learn if they have any specific coverage determinations based on your list of identified CPT® codes. Depending on your new specialty, some procedures or surgeries may be considered experimental, cosmetic, or non-covered, or require payer-specific modifiers or other billing guidelines.

Professional associations your providers are affiliated with are useful resources for finding this specialty-specific information. For example, American College of Obstetricians and Gynecologists (ACOG), Society of Thoracic Surgeons (STA), and American Association of Orthopedic Surgeons (AAOS) all have websites with valuable information for practice management and coding. Often, these resources provide specialty-specific coding and billing workshops, newsletters, or coding services that can help you navigate the ins and outs of your new specialty.

AAPC is also a significant resource for specialty coders. By logging onto the member forum, you can pose questions or search for previously asked questions in a number of specialty areas, with answers usually provided by senior coders who routinely provide links to regulatory guidance. Most importantly, you can obtain additional training and specialty certification through AAPC’s conferences, workshops, and specialty certification examinations.

Networking through your local AAPC chapter can help introduce you to coders who may have experience in your new specialty. You can also arrange to be on the mailing lists of neighboring local chapters, so if they are holding a meeting regarding your specific specialty, you can attend, learn, and network.

Learning a new coding specialty can be a fun and interesting challenge if you’re motivated and apply a systematic and careful approach to setting up your coding and billing protocols. You can also use this approach to prepare for a job interview in a new and exciting specialty. Take advantage of available resources to add value to your current employer and add experience to your resume.

 

Pam Brooks, CPC, is the physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H. She holds a Bachelor of Science degree in Adult Education and Workplace Training from Granite State College, and is working on her master’s in Health Administration at St. Joseph’s College of Maine. She is a past secretary of the Seacoast-Dover N.H. AAPC local chapter.

April 1st, 2012

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AAOS Publishes New Tx Guideline for Vertebral Fractures

The American Academy of Orthopaedic Surgeons (AAOS) board of directors recently approved at their Sept. 24 meeting a new clinical practice guideline on the treatment of osteoporotic spinal compression fractures. The guideline includes 11 recommendations, but only two of those recommendations carry any real weight, the board said.

Whereas the board found that for nine of the 11 recommendations the evidence was insufficient or conflicting and did not enable the workgroup to make a recommendation for or against the intervention, The Clinical Practice Guideline on the Treatment of Symptomatic Osteoporotic Compression Fractures includes one recommendation that is supported by moderately high-quality evidence and one strong recommendation supported by evidence that the workshop found both “overwhelming and compelling.”

The first recommendation based on moderately high-quality evidence suggests that patients who have radiographic evidence of an osteoporotic spinal compression fracture with correlating clinical signs and symptoms suggesting an acute injury (within five days of an identifiable event or onset of symptoms) and who are neurologically intact be treated with calcitonin for four weeks.

The single strong recommendation in the guideline is that for vertebroplasty (CPT® codes 22520-22522). “We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact,” said the AAOS board of directors.

The guideline considers kyphoplasty (CPT® codes 22523-22525) to be an option (with a weak recommendation), however. “Although kyphoplasty and vertebroplasty are similar procedures, the evidence supports treating them differently within the recommendations,” said the board.

The guideline is available on the AAOS website.

October 15th, 2010

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When CMS and AMA Disagree, How Do You Code?

The American Medical Association’s (AMA) Current Procedural Terminology (CPT®) guidelines state that you can append modifier 50 Bilateral procedure to surgical procedure codes (27215-27218) for pelvis injuries. Bill Medicare for a procedure from this code range with modifier 50 appended, however, and your claim will likely be denied.

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April 5th, 2010

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Take the Sting Out of Injection Coding

AAPC member Mary LeGrand, RN, MA, CPC, CCS-P, provides orthopaedic specialists advice on injection coding in AAOS — the American Academy of Orthopaedic Surgeons’ online newsletter.

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October 19th, 2009

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