Coding Consult: Bone up on fractures

September 5, 2003

Use new E codes for trendy accidents


Coding Consult

Bone up on fractures

Jump to:Choose article section... Specificity is the key Coding for evaluation only

To get adequately reimbursed for treating simple fractures in the primary care setting you have to pinpoint the correct code out of CPT's vast section on the musculoskeletal system. Fracture codes are spread throughout the section (20000-29999), but organized starting with the head and working down the body. For example, fractures of the skull, facial bones, and temporomandibular joints are toward the beginning of the section (21300-21497).

You more typically treat fractures or dislocations of the upper arm and elbow (24500-24685) or forearm and wrist (25500-25695). Hand and finger fractures or dislocations begin with 26600 and end with 26785. The musculoskeletal section then progresses to fractures and/or dislocations of the pelvis and hip joint (27193-27266); femur and knee joint (27500-27566); and lower leg and ankle joint (27750-27848). Codes conclude with foot and toes (28400-28675).

Specificity is the key

Correct coding requires you to identify the precise bones affected (tibia or fibula, for instance, not lower limb) as well as the location of the fracture on the bone—proximal or distal—and whether treatment was closed or open. Ankle fractures are more complicated, forcing a distinction between the type of fracture—bimalleolar or trimalleolar—as well as determining if the fracture is of the malleolus or the distal weight-bearing portions of the tibia and/or fibula.

Whether you administer anesthesia makes a difference, too. For example, you'd have to choose between 27830 (closed treatment of proximal tibiofibular joint dislocation; without anesthesia) and 27831 (. . . requiring anesthesia).

The element you need to determine next is whether the case involves manipulation.

"Fracture displacement is the key," says Susan Welsh, former billing co-ordinator for the department of orthopedics at Vanderbilt University in Nashville. When a fracture is not displaced, the bone is in or close to anatomic alignment, and you don't have to perform manipulation to treat the break. But if the bone is significantly out of place, you may need to "move," "distract," "reposition," "realign," or "apply tension" to manipulate the displaced bone into correct anatomic position, Welsh explains. In the case of minimal misalignment, as often occurs with incomplete fractures, you may not need to perform any manipulation.

For instance, a man falls off his bicycle and fractures the middle phalanx bone of his index finger. X-rays show a hairline fracture that is relatively in alignment. Because no manipulation is involved, report 26720 (closed treatment of phalangeal shaft fracture . . . finger or thumb; without manipulation, each).

In contrast, if you have to reposition the displaced bone, you would instead assign 26725 (. . . with manipulation, with or without skin or skeletal traction, each). Manipulation of a fracture is also known as a reduction or setting of the fracture "by the application of manually applied forces." CPT refers to strapping as "skin traction—the application of a force (longitudinal) to a limb using felt or strapping applied directly to the skin only."

By definition, application of the splint is included in code 26725. This is confirmed in the instructional notes located under the Application of Casts and Strapping codes (29000-29799). Remember that only the initial cast, splint, or strapping is included in the fracture care code. If you need to replace the patient's splint at a subsequent visit, bill 29130 (application of finger splint; static) for the replacement splint.

Coding for evaluation only

In a primary care office, your coding most often involves evaluating but not treating a fracture. When dealing with open fractures and complex wounds requiring manipulation or fixation, you may provide initial stabilization only to protect the fractured bone and to provide pain relief until the patient gets to an orthopedic specialist or the emergency department. If you don't assume ongoing or comprehensive care for the fracture, you should use the initial application of casts and strapping codes (29000-29590) rather than the fracture care codes.

For example, a young woman presents with a fractured shoulder from falling down stairs. X-rays show that she fractured her greater humeral tuberosity. You apply a long arm splint to stabilize the shoulder and arm until an orthopedic surgeon can treat the patient the next day.

Because you don't treat the fracture, don't report a fracture care code. You render the initial care only and provide no other procedure or treatment, so the casting and strapping codes appropriately describe the service—29105, (application of long arm splint [shoulder to hand]) and the payer-preferred supply code, such as Q4017 (cast supplies, long arm splint, adult [11 years +], plaster), Q4018 (cast supplies, long arm splint, adult [11 years +], fiberglass), or 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]).

In addition, assign the appropriate level E&M service, such as 99211-99215 (office or other outpatient visit for the evaluation and management of an established patient. . .) for the physician's history, evaluation, and medical decision-making prior to applying the splint. Append the office visit code with modifier –25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to indicate a significant, separately identifiable E&M from the splint application.

Some fads have spawned their own codes: If a kid falls off his Razor, you can use an E code, E885.0 (fall from [nonmotorized] scooter), as a supplementary code when treating injuries resulting from such falls. Paintball injury? Use E985.7 (injury by firearms, air guns, and explosives, undetermined whether accidentally or purposely inflicted; paintball gun).

"The fact that E codes are supplemental means they are not used for the primary diagnosis," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians. If a patient falls off a scooter and breaks an arm, use the appropriate fracture diagnosis code and report the E code in addition as a means of explaining the accident.


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Dorothy Pennachio. Coding Consult: Bone up on fractures.

Medical Economics

Sep. 5, 2003;80:17.