Emergency department (ED) billing for fracture care is a frequently misunderstood area. Contrary to common misconceptions, emergency physicians can and do bill for fracture care provided in the ED. The key to accurate billing lies in differentiating between restorative care and definitive care. Understanding this distinction, along with the appropriate CPT coding guidelines for 2018, ensures proper reimbursement for services rendered. This guide will clarify these guidelines, focusing on how to correctly code fracture care in the ED setting.
Restorative Care: Manipulation and Fracture Reduction
Restorative care in fracture management typically involves manipulation, aiming to restore the bone to its original alignment. In the ED, this is often necessary for certain types of fractures. Common examples of fractures requiring restorative care that are frequently seen in the emergency setting include:
- Finger fractures
- Toe fractures
- Metacarpal fractures
- Distal fibular fractures
- Bimalleolar and trimalleolar ankle fractures
- Distal radius fractures
For accurate coding, detailed procedure notes from the physician are crucial. These notes should clearly document the manipulation performed.
Example of Restorative Care Coding:
Consider a patient presenting to the ED with significant wrist pain following a fall. An X-ray confirms a distal radius fracture. The emergency physician performs a closed reduction, manipulating the fractured bone back into alignment. In this scenario, the appropriate CPT code to report is 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). This code accurately reflects the restorative care provided – closed treatment of the distal radius fracture with manipulation.
Alt text: Emergency department physician examining wrist x-ray for fracture care billing determination, focusing on restorative treatment.
Definitive Care: When the ED Provides Complete Fracture Treatment
Definitive care, in the context of ED fracture management, refers to situations where the emergency physician provides the complete and final treatment for the fracture, similar to what a specialist might offer in an initial consultation. Fractures commonly managed with definitive care in the ED often include:
- Finger fractures
- Toe fractures
- Clavicle fractures
A frequently overlooked, yet highly relevant, CPT code for definitive fracture care in the ED is 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each). This code is applicable when an emergency physician provides comprehensive care for a phalanx fracture, even without manipulation.
Example of Definitive Care Coding:
Imagine a patient who injures their toe. Upon examination in the ED, an X-ray reveals a phalanx fracture. The emergency physician proceeds to:
- Address the patient’s pain.
- Thoroughly review the patient’s medical history and current condition.
- Provide detailed instructions regarding the expected symptom progression, the healing timeline, and potential complications.
- Apply buddy taping to the injured toe, securing it to the adjacent toe for support.
Following this, the patient is discharged with or without a pain management prescription. Crucially, in this example, while no manipulation was performed, the emergency physician provided comprehensive, definitive care. This level of care, mirroring the initial management by a specialist, warrants reporting CPT code 28510 for each fractured phalanx treated.
It’s important to note the typical follow-up timeframe associated with definitive care. Generally, a follow-up appointment is scheduled within five to seven days. If a specialist consultation is deemed necessary in less than a week, it suggests the ED physician likely provided palliative care or initial stabilization rather than definitive care.
Alt text: ICD-10-CM coding book image, representing the importance of accurate diagnosis codes for fracture care billing in 2018 guidelines.
E/M Services and Modifier Application in Fracture Care Coding (2018 Guidelines)
Evaluation and Management (E/M) services are integral to fracture care. A detailed examination is typically necessary to assess the extent of the injury, evaluate neurovascular status, and identify any associated injuries. Thorough documentation of these examinations is essential for accurate E/M coding. Fracture treatment E/M services often begin at level IV due to the complexity and thoroughness required.
Because fracture care is categorized as a major procedure with a 90-day global period, specific modifiers are necessary when billing E/M services in conjunction with fracture care.
Modifier 57: Decision for Surgery
When an E/M service is performed on the same day as, or the day before, a major surgical procedure (like fracture care), and the decision for surgery is made during that E/M encounter, modifier 57 (Decision for surgery) must be appended to the appropriate E/M code. This modifier indicates that a significant, separately identifiable E/M service was performed, leading to the decision to perform the fracture care.
Modifier 54: Surgical Care Only
In situations where the emergency physician provides the surgical (fracture care) portion of the treatment, but the postoperative management will be handled by a specialist, modifier 54 (Surgical care only) should be appended to the CPT code for the fracture care service. This informs the payer that the ED physician is only billing for the preoperative and intraoperative components of care, and postoperative care is the responsibility of another provider. When modifier 54 is used, the ED physician typically receives approximately 70 percent of the reimbursement associated with the complete fracture care service, reflecting the surgical portion of the global package.
Alt text: Collection of medical coding books, emphasizing resources needed for fracture care CPT coding guidelines 2018 compliance.
Conclusion: Mastering Fracture Care Coding in the ED
Accurate billing for fracture care in the emergency department relies on a clear understanding of the distinction between restorative and definitive care, and the appropriate application of CPT coding guidelines, particularly those relevant to 2018. By correctly identifying the type of care provided and utilizing modifiers 57 and 54 when necessary, emergency physicians and coding professionals can ensure compliant and accurate reimbursement for the valuable fracture care services delivered in the ED setting. Remember to always consult the most current coding guidelines and payer-specific policies for the most up-to-date information.
