Answers to Your Auditing & Compliance Questions

March 4th, 2019 - Namas
Categories:   Compliance   Emergency Medicine   Pediatrics   Physical Medicine|Physical Therapy  

National Alliance of Medical Auditing Specialists (NAMAS) hosts a forum where auditing and compliance professionals can get answers to their questions, and exchange information with other professionals across the country. Recently, we've received the following question regarding fracture care that we'd like to share below.


Q: I recently noticed CPT 26600, for closed treatment of metacarpal fracture without manipulation. I don't understand why you'd bill for this. If I see a metacarpal fracture in the clinic and bill 99204, then I splint the patient and bill 29125, it seems like double counting to then bill 26600 because if its 'without manipulation', then you are just treating the patient with a splint, which I've already billed for. However, 26600 bills 2.6 wRVUs, so I don't want to miss out an all of the metacarpal fractures that I treat if it applies.

I am not sure I am reading it correctly. Should the provider bill the office visit with a 25 modifier, the treatment of 26600 if he didn't manipulate and the 29125 for applying the splint?


A: There are several things to consider in this scenario. First, the initial splint application is included in the charge for the fracture, so not separately reportable. If he chooses to report the fracture care, the splinting can’t be reported. Also, unless the patient has significant comorbidities that are documented as affecting the complexity of the decision about how to treat the fracture, a level four office visit would not be supported by the medical necessity for a metacarpal fracture. Finally, it is often difficult to support a significant, separately identifiable E&M service above and beyond the typical preoperative and postoperative work included in the reimbursement for the procedure, so it is very possible modifier -57 would not be supported. It all goes back to the documentation. (Modifier -25 is only for minor procedures with 0 or 10-day global periods. -57 is needed when reporting an E&M for 90-day global services.)

There are two schools of thought for billing closed treatment without manipulation of hand/foot fractures. The first is to bill the fracture care and any imaging and supplies used for treatment during the initial visit. This locks the provider into 90 global care, so the follow-up visits are not reportable. If the provider does not expect the patient to actually require follow-up visits then fracture care is really not supported. Reporting this way, the wRVU is 2.60.

The second is to bill in an itemized manner. The E&M and splint application are reported on the first visit, then any follow-up visits are reported separately. For the typical new patient, we would expect 99203 (1.42) and 29125 (0.50) for the initial encounter and 99213 (0.97 x the number of follow-ups necessary) for medically necessary follow-up visits. If only one follow-up visit was necessary, the total wRVUs would be 2.89. As you can see, this is usually the option that is most advantageous to the provider. (All levels of service in this example assume the documentation supports the key elements and medical necessity to report the level of service.)

Also, since most insurance policies apply the fracture care to the patient’s deductible, billing the fracture care potentially creates an upset patient when they receive a perceived large bill for “just putting a splint on it.” Many practices have made a policy to not bill for closed treatment without manipulation in the interest of customer service and patient satisfaction.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association