OR
Orthopaedics

Coding: nonoperative fracture care

April 07, 2012.
Eric G. Meinberg, MD,

Educational Objectives

The goal of this program is to increase the accuracy of coding for operative and nonoperative procedures. After hearing and assimilating this program, the clinician will be better able to:

1.Discuss the proper use of the global fracture care code when multiple providers are involved.

Summary

Background: Centers for Medicare and Medicaid Services (CMS) requires use of new and established patient codes (not special ones), eg, cannot bill for consultations; electronic medical record (EMR) system greatly aids with coding; issues generally involve lack of documentation

Coding: components — 1) patient history (eg, problem focused, extended problem focused, detailed, or comprehensive); based on chief complaint, history of present illness (HPI), review of systems (ROS), and past medical history (PMH); 2) physical examination (PE); 3) complexity of medical decision making; example — level 3 new patient requires 4 elements for HPI; 3 elements for each PMH and ROS; 12 elements for PE; moderate complexity medical decision making; documentation of threat to function intensifies complexity of decision making; example — level 4 established patient requires 2 to 9 elements for ROS; 2 elements for PMH; and moderate complexity medical decision making; consider intensity of cognitive labor; templates available online; laminated sheet to check off elements during office visit (OV) helps to code and bill appropriately; for inpatient hospital visits, codes consist of 3 levels with advancing complexity; time coding — document .50% of face-to-face encounter spent in counseling and coordinating patient care

Global surgery package: combines reimbursement for complete operative care; includes all necessary services performed in 90-day global period; can still charge professional fees for interpreting radiographs and facility fees; may receive entire global fee without modifier for fracture care only if initial cast applied, perform initial follow-up examination, and perform all management until injury healed; surgical care reimburses at 70%; follow-up after someone else performs surgery reimburses at 20%; initial evaluation without cast application reimburses at 10%; split fracture care (multiple providers involved) must be coordinated

Examples: 1) ED physician receives majority of reimbursement for preoperative work-up, initial x-rays, diagnosis, evaluation, and intraoperative procedure (ie, apply splint or perform reduction); ED physician codes for fracture care with modifier 54 (surgical care only); orthopedic surgeon bills modifier 55 (postoperative care only); 2) ED physician requests orthopedic consultation; surgeon performs closed reduction, places splint, and schedules follow-up; ED physician reports 99281 code for problem-focused examination; surgeon codes for operative management with manipulation (22762) and provides global service for 90 days at no charge; may attach modifier 57 if decision then made for surgery; 3) E/M code with splint or cast application only when medically necessary and documented (add modifier 25)

Other: modifier 57 — decision for surgery; separates evaluation and consultation-based decision for surgery from actual surgery; also counts for manipulative fracture reduction; modifier 76 — re-reduction performed alone; refers to nonsurgical service repeated in separate session; complications (eg, loss of reduction following surgery) coded as modifier 78

E/M and Current Procedural Terminology (CPT) codes for fracture treatment: anticipate number of follow-up visits to determine which code to use; example — distal radius fracture that requires manipulation, 11.7 RVUs; if no manipulation required, 6.7 RVUs; must match or exceed RVU value for coding fracture care to make office visits worthwhile; can bill separately for each office visit as long as total RVUs do not exceed RVUs from global code for fracture care; recognize which nonoperative CPT fracture codes generate more RVUs (eg, fractures of acetabulum, tibial spine or shaft, proximal humerus); smaller fractures (ie, involving hands or feet) reimburse better by coding for office visits separately

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Meinberg is a consultant for Amgen and Medtronic. The planning committee reported nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

Lecture ID:

OR350703

Qualifies for:

Trauma

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation