PRESENTED BY: JOHN STIMLER, DO, CPC, CHC, FACEP BSA HEALTHCARE AND BSA HEALTHCARE ADVISORY GROUP

Transcription

1 PRESENTED BY: JOHN STIMLER, DO, CPC, CHC, FACEP BSA HEALTHCARE AND BSA HEALTHCARE ADVISORY GROUP

2 TOPICS (1) Fracture types ICD-10-CM diagnostic coding CPT procedure coding Fracture care treatments: Manipulated Non-manipulated 2

3 TOPICS (2) Fracture care definitions: Restorative care Definitive care Modifiers: -54 with fracture or dislocation codes -25 with E/M codes 3

4 TOPICS (3*) Splint application coding Splint types: Pre-packaged or off-the-shelf Created or fabricated Documentation requirements - Government vs. non-governmental payers: Application by provider Placement and/or completed splint evaluation by provider 4

5 DEFINITIONS (1) Fracture A break in the bone usually due to traumatic injury. Pathologic Caused by benign bone cysts, malignancy, infection, or select metabolic abnormalities 5

6 DEFINITIONS (2*) Closed A broken bone that does not penetrate the skin and is therefore not open to the environment. Open An open fracture that causes a break in the skin, which is then exposed to the environment. If provider fails to document open vs. closed, use closed 6

7 TYPES OF FRACTURES Stress Fracture Linear Fracture Compression Fracture Compacted Fracture Torus Fracture Buckled Fracture Depressed Fracture Elevated Fracture Comminuted Fracture Avulsed Fracture Impacted Fracture Segmental Fracture Simple Fracture Transverse Fracture Spiral Fracture Greenstick Fracture 7

8 COMMON TYPES OF FRACTURES 8

9 SPATIAL RELATIONSHIP BETWEEN FRACTURE FRAGMENTS 9

10 DISPLACED VS. NON DISPLACED 10

11 DIAGNOSTIC CODE CHOICE 11

12 RADIOLOGY REPORTS UTILIZATION (1) Use radiology report results to assign a more specific fracture diagnostic code Usually lists the exact location on bone Laterality (right vs. left) is also key No need to consult the ED provider 12

13 RADIOLOGY REPORTS UTILIZATION (2*) Example: Final diagnosis: left wrist fracture (ICD- 10 code S62.102A) Radiology report: fracture distal radius Code: ICD-10 code S52.502A for Fracture, left radius, distal end should be assigned 13

14 MULTIPLE FRACTURES? (1) Separate codes should be assigned for multiple fractures unless the Alphabetic Index or Tabular List provides instruction to the contrary. If multiple fractures, look to see if combination fracture codes exist 14

15 MULTIPLE FRACTURES? (2*) Multiple traumatic injuries such as fractures of the index finger distal phalanx and ring finger proximal phalanx Examples: S62.631A - Initial encounter fx distal phalanx of index finger S62.644A - Initial encounter proximal phalanx right ring finger 15

16 PATHOLOGIC FRACTURES (1) May be caused by minor trauma or occur without a history of trauma Underlying disease process such as osteoporosis, bone cysts, metastasis, or metabolic conditions Causes significant weakness to bone Often considered spontaneous in nature 16

17 PATHOLOGIC FRACTURES (2*) Example: Final diagnosis: pathological fracture of left wrist Radiology report: fracture distal left radius Code: Look under Fracture, site, pathological and code ICD M84.434A, Pathological fracture, left radius, initial 17

18 STRESS FRACTURES Occur when bones develop fatigue from repetitive forces Metatarsal most common Example: Final diagnosis: Stress fracture metatarsal Radiology report: Fracture left third metatarsal Code: Look under Fracture, stress, metatarsal and code M84.375A Stress fracture, left foot, initial 18

19 ICD-10-CM CODE CHOICE SELECTION What exact bone(s) is/are involved? Usually found in the ED provider s final diagnosis or radiologist s x-ray interpretation What specific area of the bone is involved (distal, shaft, proximal) and side (R or L)? Was the fracture closed or open? If no documentation of open or closed, default to closed fracture 19

20 CPT CODE CHOICE ISSUES 20

21 GENERAL THOUGHTS CPT code descriptions must correlate with ICD-10 code descriptions Choice of CPT code depends on type of treatment rendered 21

22 TREATMENT TYPES (1) Closed treatment The fracture site is not surgically opened Most common in ED Open treatment The fractured bone is repaired via a surgical incision Most common in OR 22

23 TREATMENT TYPES (2*) Manipulation The reduction or restoration of the correct alignment of the bone Manipulation can be performed in the ED or the OR Percutaneous Skeletal Fixation Fixation (i.e., pins) are placed across the fracture site through small puncture wounds in the skin Pins are usually placed with x-ray imaging and are usually not directly over the fracture site Open treatment and/or skeletal fixation are generally performed in the OR 23

24 RESTORATIVE VS. DEFINITIVE CARE Restorative care encompasses: A reduction of a joint dislocation; or The re-alignment of a fracture to its normal anatomical alignment. Definitive care encompasses: Treatment that is necessary to bring the usefulness, range of motion, and strength of a particular bone or joint to its original state prior to the injury. 24

25 HELPFUL CHART ELEMENTS (1) Order of pre- and post-reduction x-rays A radiological study indicating the exact bone that is fractured and whether it is non-displaced or displaced Manipulation (reduction or restoration) by the ED provider as procedure or in ED course 25

26 HELPFUL CHART ELEMENTS (2*) Immobilization by taping, strapping, casting or splinting Pain management including IV, IM, or oral medications, and/or a prescription at discharge with advice to purchase over-thecounter medications Discharge referral or a call for direct referral or transfer of care to the orthopedist or another physician 26

27 WHAT IS INCLUDED IN FRACTURE CARE? The initial immobilization (cast, splint, etc.) of the fracture is included in the fracture care codes ED provider directly places the splint or evaluates the results of a splint placed by someone else X-ray interpretations are not included in fracture care codes 27

28 -54 MODIFIER INCLUDES Nasal fractures (21310, 21315) TMJ Dislocation (21480) Metatarsal-phalangeal dislocations of foot (28630) Inter-phalangeal joint dislocations of toes (28660) Does not include finger dislocations!! 28

29 FRACTURE MANIPULATION (1) Uncommon in most EDs with the exception of distal ankle (i.e., 27762, 27768, 27788, 27810, 27818) Some EDs may either have limited orthopedic surgical coverage or have a specific coverage arrangement between the ED and an orthopedic group 29

30 FRACTURE MANIPULATION (2) Under these arrangements the ED physicians provide the majority of fracture manipulations as well as splinting or casting. Examples of additional manipulations: Colles or Smith fx of wrist (25605) May include other fractures (such as humerus or forearm) if documented by ED provider 30

31 FRACTURE MANIPULATION (3*) In these cases, the follow-up care for the fracture or dislocation is provided by the orthopedic doctor after the majority of fracture care has been provided by the ED physician The -54 modifier is required for these types of cases 31

32 RE-LOCATIONS OF DISLOCATIONS (1) The ED physician also provides the primary re-location of various dislocated joints Examples: TMJ DP joints of fingers and toes PIP joints of fingers and toes MP joints of hands and feet Shoulder 32

33 RE-LOCATIONS OF DISLOCATIONS (2*) Examples (cont.): Nursemaids elbow Elbow Patellar Hip (regular and prosthetic) Ankle The majority of dislocations require that the -54 modifier be appended to the procedure code 33

34 REPORTING AN E/M WITH A FRACTURE CARE CODE (1) It is appropriate to report an E/M code along with fracture care codes when supporting documentation exists of a separately identifiable exam Fracture care codes are considered surgery codes and the initial evaluation that determines the need for surgery should be reported separately 34

35 REPORTING AN E/M WITH A FRACTURE CARE CODE (2*) Supporting documentation must include the history, exam, and medical decision making that justifies the final E/M code These cases are typically trauma cases that require work-up and therapy for more widespread potential injuries 35

36 USE OF MODIFIER WITH E/M CODE Definition: significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service -25 most commonly used with an E/M code 36

37 72-HOUR RULE No longer required by most coders Why? Because many referrals are not seen within 72 hours of the ED visit 37

38 SPLINT APPLICATION CODING (1) Splint application stabilizes a fracture Code is assigned if fracture or dislocation codes are NOT billed or coded for An initial splint and/or strapping service is provided to give patient comfort following contusions, strains, or swelling posttrauma 38

39 SPLINT APPLICATION CODING (2*) Coded along with an E/M code Note: Intent of CPT casting or strapping code series is same for both professional and outpatient hospital reporting 39

40 SPLINTS DEFINITION AND TYPES (1) Splints Appliances that are made of various materials and are used for immobilization of a bone or joint to help promote healing while protecting the bone or joint from further injury or deformity. No indication as to whether the splint is static or dynamic? The static splint should be assigned. 40

41 SPLINTS DEFINITION AND TYPES (2*) Static Splint A splint without moveable parts, used for positioning, stability, protection, or support (by far the most common in ED). Dynamic Splint A splint with moveable parts that provides mobility for weak or absent muscle strength (usually not placed in ED). 41

42 PRE-FABRICATED SPLINTS DO WE CODE FOR THESE? (1) Pre-fabricated or off-the-shelf types of splints should not be coded and billed for any payer class, including self-pay. CMS and CPT state: In order to code and bill for a splint, the splint must be created. 42

43 PRE-FABRICATED SPLINTS DO WE CODE FOR THESE? (2*) Placing off-the-shelf or pre-packaged splints is a bundled service when performed on the same day as an E/M service and should not be billed separately. Medicare B News Noridian CMS Administrative Services (NAS) Issue #237, May 29, 2007; CPT Assistant February 1996, Volume 6, Issue 02; p. 3 43

44 SPLINTS CUSTOM VS. PRE-FAB (1) Boxer splint Ankle stirrup splint (ankle sugar tong) Radial & Ulnar gutter splint Long Arm Splint Short Arm Volar Splint Sugar Tong Splint Long Leg Splint (not prefab knee immobilizer) Posterior Ankle Splint Posterior Elbow Splint Plaster Splint OCL (plaster) Splint Orthoglass (fiberglass) Splint Custom Custom Custom Custom Custom Custom Custom Custom Custom Custom Custom Custom 44

45 SPLINTS CUSTOM VS. PRE-FAB (2) Stirrup Splint Double Sugar Tong Splint Long Double Sugar Tong Splint Thumb Spica Splint Medial Lateral Splint Dorsal Volar Splint Coaptation Splint Swede Brace Splint Durabracer/3Dwalker/ equalizer boot Figure 8 thumb Splint Jones Dressing/Bulky Jones Custom Custom Custom Custom Custom Custom Custom Custom Custom Custom Custom 45

46 SPLINTS CUSTOM VS. PRE-FAB (3*) Cock-up Splint Knee immobilizer Aircast /Airsplint Hard Shoe Bledsoe Brace Posterior Knee Splint Aluminum Knee Splint Aluminum Finger Splint Volar Finger Splint Post Op Shoe Custom or Pre-Fabricated Pre-Fabricated Pre-Fabricated Pre-Fabricated Pre-Fabricated Pre-Fabricated Pre-Fabricated Pre-Fabricated Custom or Pre-Fabricated Pre-Fabricated 46

47 LONG ARM SPLINT 47

48 SUGAR TONG FOREARM SPLINT 48

49 ULNAR GUTTER SPLINT 49

50 POSTERIOR FOREARM SPLINT WITH 2 ND AND 3 RD DIGIT EXTENSION 50

51 THUMB SPICA SPLINT 51

52 STIRRUP AND POSTERIOR SPLINT 52

53 POSTERIOR AND STIRRUP SPLINT LOWER LEG 53

54 MOST COMMONLY USED CODES IN EMERGENCY MEDICAL PRACTICE (NUMERICAL ORDER BY CPT CODE) 54

55 HEAD (NASAL BONES AND TMJ) 21310: Closed treatment of nasal bone fracture; without manipulation 21315: Closed treatment of nasal bone fracture; without stabilization 21480: Closed treatment of temporomandibular dislocation; initial or subsequent No -54 modifier required 55

56 THORAX 21800: Closed treatment of rib fracture; uncomplicated, each (DELETED!) 21820: Closed treatment of sternum fracture 56

57 SPINE (VERTEBRAL COLUMN) 22305: Closed treatment of vertebral (spinous) process fracture(s) Note: Do NOT use or closed treatment of vertebral body fracture(s) since this also requires casting or bracing that is not usually performed in the ED 57

58 SHOULDER (1) 23500: Closed treatment of clavicular fracture; without manipulation 23540: Closed treatment of acromioclavicular dislocation; without manipulation (Note: Code is for grade I and II only which do not require surgery with pin placement) 23570: Closed treatment of scapular fracture; without manipulation 58

59 SHOULDER (2*) 23650: Closed treatment of shoulder dislocation; with manipulation; without anesthesia 23665: Closed treatment of shoulder dislocation; with fracture of greater humeral tuberosity; with manipulation 23675: Closed treatment of shoulder dislocation; with fracture of surgical or anatomic neck fracture; with manipulation (frequently managed in OR) 59

60 ELBOW 24600: Treatment of closed elbow dislocation; without anesthesia 24640: Closed treatment of radial head subluxation in child; nursemaid s elbow; with manipulation No -54 modifier needed Usually no need for referral since proper treatment resolves the problem immediately after reduction of the nursemaid s elbow 60

61 HAND AND FINGERS (1) 26600: Closed treatment of metacarpal fx, single; without manipulation; each bone 26605: Closed treatment of metacarpal fx single: with manipulation; each bone 26720: Closed treatment of phalangeal shaft fracture; proximal or middle phalanx; finger or thumb; without manipulation (Note: Confirm that no angulation, mal-alignment, or rotation present that may require K-wire placement for stabilization) 61

62 HAND AND FINGERS (2) 26725: Phalangeal fracture; with manipulation, each OK to code these primarily since the ED physician usually performs the service 26750: Closed treatment of distal phalangeal fracture; finger or thumb; without manipulation; each 62

63 HAND AND FINGERS (3*) 26755: Closed treatment of distal phalangeal fracture; finger or thumb; with manipulation; each 26770: Closed treatment of interphalangeal joint dislocation; single; with manipulation; without anesthesia 63

64 PELVIS AND HIP JOINT 27200: Closed treatment of coccygeal fracture 27250: Closed treatment of hip dislocation; traumatic; without anesthesia 27265: Closed treatment of post-hip arthroplasty dislocation; without anesthesia 64

65 KNEE 27550: Closed treatment of knee dislocation; without anesthesia 27560: Closed treatment of patellar dislocation; without anesthesia 65

66 ANKLE 27762: Closed treatment of medial malleolus; with manipulation 27788: Closed treatment distal fibular fracture (lateral malleolus); with manipulation 27810: Closed treatment of bi-malleolar ankle fracture; with manipulation 27818: Closed treatment of tri-malleolar ankle fracture; with manipulation 27840: Closed treatment of ankle dislocation; without anesthesia 66

67 FOOT AND TOES (1) 28470: Closed treatment of metatarsal fracture; without manipulation; each 28475: Closed treatment of metatarsal fracture; with manipulation; each 28490: Closed treatment of fracture great toe, phalanx or phalanges; without manipulation 67

68 FOOT AND TOES (2) 28495: Closed treatment of fracture great toe, phalanx or phalanges; with manipulation 28510: Closed treatment of fracture; phalanx or phalanges; other than great toe without manipulation; each 28515: Closed treatment of fracture; phalanx or phalanges; other than great toe with manipulation; each 68

69 FOOT AND TOES (3*) 28630: Closed treatment of metatarsophalangeal joint dislocation; without anesthesia 28660: Closed treatment of interphalangeal joint dislocation; without anesthesia No -54 modifier required 69

70 REFERENCES From The Merck Manual of Diagnosis and Therapy, Online Medical Library, edited by Robert Porter. Copyright by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ. Available at: Accessed (7/27/2010) Current Procedural Terminology (CPT ) copyright, 2010 American Medical Association. All Rights Reserved Ingenix, All Rights Reserved Medicare B News Noridian CMS Administrative Contractor (NAS) Issue #237, May 29, 2007 CPT Assistant February 1996, Volume 6, Issue 02: page 3 70

71 THANK YOU 71