There is a common misconception that you cannot bill for fracture care in the emergency department (ED). The truth is that emergency physicians provide fracture care on a regular basis. To determine if fracture care can be billed in the ED, you must decide if the emergency physician is providing restorative care (manipulation) or definitive care (e.g., a splint or the same care an orthopedist would provide).
Some of the most common fractures presented in the ED requiring manipulation are:
- Finger fractures
- Toe fractures
- Metacarpal fractures
- Distal fibular fractures
- Bimalleolar and trimalleolar ankle fractures
- Distal radius fractures
It is important for physicians to provide a procedure note to ensure the coders can bill appropriately for the procedure performed.
For example, a patient presents to the ED with wrist pain. An X-ray is performed, revealing a distal radius fracture. The physician reduces the fracture by using manipulation (restorative care). In this situation, you would report the code for closed treatment of a distal radius fracture with manipulation (CPT® 25605 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation).
The most common fractures for which an emergency physician performs definitive care in the ED are:
- Finger fractures
- Toe fractures
- Clavicle fractures
- Rib fractures
One of the most common fracture codes not being billed in the ED is 21800 Closed treatment of rib fracture, uncomplicated, each. When a patient has a rib fracture, the physician almost always provides definitive care. The emergency physician treats the patient’s pain; reviews all medical documentation; explains the expected progression of symptoms, healing process, and potential for complications; and orders a spirometer to prevent secondary pneumonia. The patient is then discharged home with a prescription for pain management.
In the above example, the emergency physician did not perform any type of manipulation, but did provide the same treatment a “specialist” would have. This qualifies as definitive care. You would report CPT® 21800 for each rib that is fractured.
When billing for definitive care, the normal time requested for follow-up is five to seven days. If the patient needs to be seen by a specialist in less than one week, the ED physician most likely provided palliative care only, and not definitive care.
E/M Documentation, Modifier Use
When a patient is seen for a fracture, a very detailed exam is commonly required. The physician must check for the extent of the injury, neurovascular status, and other injuries. Because of this, the physician should make sure to document thoroughly. Fracture treatment evaluation and management (E/M) levels typically start at a level IV (99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity …). Because fracture care is considered a major procedure code (having a 90-day global period), you must append modifier 57 Decision for surgery to the appropriate E/M procedure code reported at the same time as fracture care.
Remember, also: When the emergency physician provides fracture care and the patient requires follow-up by the specialist, append modifier 54 Surgical care only to the CPT® code being billed. This modifier shows the preoperative and operative care only were provided in the ED, and the postoperative care will be handled elsewhere. When using modifier 54, the ED physician will typically receive 70 percent of the revenue associated with the fracture care service.
Jeannie Dean, CPC, CPC-H, CPMA, is director of client services, coding manager at Medical Reimbursement, Inc. (MRI) in Cincinnati, Ohio. She directs MRI’s coding department, compliance, and physician education. Ms. Dean has over 20 years experience in health information management (HIM) including consulting, teaching, technical, and management. She provides coding, compliance, physician documentation, and revenue cycle management services to specialty physician practice management organizations and private practices. Ms. Dean speaks for MRI and other organizations and can be reached by email at firstname.lastname@example.org.