Partnering with the global leader!

EMERGENGY DEPARTMENT-Procedures Coding

 Learning Objectives

 Define the procedures performed in ED

 Describe and Understand the Procedures in ED

 Analyse procedures documentation

 Recognize the key indicators in the procedures

 Apply the CPT coding guidelines to the procedures

 Choose the accurate CPT codes for procedures

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 2
 Common Procedures in ED

 Trigger Point Injections

 Arthrocentesis, Aspiration and/or Injections

 Moderate Sedation

 Fracture care

 Dislocation care

 Cast/Splint

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 3
 Trigger Point Injection (TPI)

 A trigger point is a painful area in a muscle. It may feel like there is “knot” in the muscle or an area of tightness

 Trigger points are focal, discrete spots of hypersensitive irritability identified within bands of muscle and may be
formed by acute or repetitive trauma to the muscle tissue, which puts too much stress on the fibers.

 Trigger point injection (TPI) is a

treatment to painful areas of
muscle that contain trigger points

 Indications:

 Myofascial Pain

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 4
 Trigger Point Injection (TPI)
 The physician identifies the trigger point injection site by palpation or radiographic imaging and marks the injection
site. The needle is inserted and the medicine is injected into the trigger point.

 The injection may be done under separately reportable image guidance. After withdrawing the needle, the patient is
monitored for reactions to the therapeutic agent. The injection procedure is repeated at the other trigger points for
multiple sites.

 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles

 If radiographic imaging performed report:

 76942 Ultrasound radiographic imaging,

 77002 Fluoroscopic radiographic imaging,

 77021 Computed Tomography radiographic imaging

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 5
 Trigger Point Injection (TPI)

 67-year-old male is seen in ED for hand pain. The physician evaluated the patient and identified the trigger point
injection site by palpation and fluoroscopic imaging and marks the injection site. The needle is inserted and the
medicine is injected into the Flexor carpi ulnaris muscle trigger point. After withdrawing the needle, the patient is
monitored for reactions to the therapeutic agent. The injection procedure is repeated with 5 injections at the other
trigger points.

 Answer: 20552, 77002

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 6
 Arthrocentesis, Aspiration and/or Injection
 Arthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule. It is also
known as joint aspiration. Arthrocentesis is used in the diagnosis of gout, arthritis.

 A joint injection is a procedure used in the treatment of inflammatory joint conditions, such as arthritis, gout,
tendinitis, bursitis and occasionally osteoarthritis.

 After administering a local anesthetic, the physician inserts a needle through the skin and into a joint or bursa. A
fluid sample may be removed from the joint for examination or a fluid may be injected for lavage or drug therapy. The
needle is then withdrawn and pressure is applied to stop any bleeding.

 Indications:

 Arthritis

 Gout

 Joint Disorders

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 7
 Arthrocentesis, Aspiration and/or Injection
Joint Imaging Guidance Ultrasound Fluoroscopic CT MRI
Arthrocentesis, Aspiration and/or Injection

Without 20600
Small
With 20604 20600, 77002 20600, 77012 20600, 77021

Without 20605
Intermediate
With 20606 20605, 77002 20605, 77012 20605, 77021

Without 20610
Major
With 20611 20610, 77002 20610, 77012 20610, 77021

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 8
 Arthrocentesis, Aspiration and/or Injection

 Indications: Inflammatory arthritis of right knee

 Procedures: After consent was obtained, using sterile technique the right knee was prepped and plain Lidocaine
1%was used as local anesthetic. A needle was inserted into the knee joint without difficulty and less than one ml's of
clear yellow coloured fluid was withdrawn and sent for laboratory testing. The procedure was well tolerated. The
patient is asked to continue to rest the joint for a few more days before resuming regular activities. It may be more
painful for the first 1-2 days. Watch for fever, or increased swelling or persistent pain in the joint. Call or return to ED
prn if such symptoms occur or there is failure to improve as anticipated.

 Answer: 20610

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 9
 Moderate Sedation

 Moderate Sedation or Moderate Conscious Sedation is a drug-induced depression of consciousness during which
patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

 Examples:
 Midazolam
 Fentanyl
 Propofol
 Etomidate
 Ketamine

 Indications:

 To perform or facilitate the procedures (Closed reduction of fractures and/or dislocations)

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 10
 Moderate Sedation
Moderate Sedation
Same Physician Performing the Diagnostic or other than the Physician Performing the Diagnostic or
Therapeutic Service (Same Physician) Therapeutic Service (Different Physician)

Patient age Patient age

Younger than 5 years 5 years or older Younger than 5 years 5 years or older

Duration Duration Duration Duration

Less than 10 10 or more Less than 10 10 or More Less than 10 10 or More Less than 10 10 or More
Minutes Minutes Minutes Minutes Minutes Minutes Minutes Minutes

Do not report Do not report Do not report Do not report

Sedation Initial 15 Sedation Initial 15 Sedation Initial 15 Sedation Initial 15
Minutes Minutes Minutes Minutes
99151 99152 99155 99156

Less than 8 Minutes Less than 8 Minutes Less than 8 Minutes Less than 8 Minutes
after each unit do not after each unit do not after each unit do not after each unit do not
Report 99153 Report 99153 Report 99157 Report 99157

Each Additional 15 Each Additional 15 Each Additional 15 Each Additional 15

Minutes 99153 Minutes 99153 Minutes 99157 Minutes 99157

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 11
 Moderate Sedation

Moderate Sedation provided by same Moderate Sedation provided by

Total Intra-service time for
Patient Age physician also performing the different physician, not the physician
Moderate Sedation (Duration)
procedure who is performing the procedure

Less than 10 minutes Any age Not reported separately Not reported separately

< 5 years 99151 99155

10-22
5 years or older 99152 99156
< 5 years 99151 + 99153 X 1 99155 + 99157 X 1
23-37
5 years or older 99152 + 99153 X 1 99156 + 99157 X 1
< 5 years 99151 + 99153 X 2 99155 + 99157 X 2
38-52
5 years or older 99152 + 99153 X 2 99156 + 99157 X 2
< 5 years 99151 + 99153 X 3 99155 + 99157 X 3
53-67 (53 min. - 1 hr. 7 min.)
5 years or older 99152 + 99153 X 3 99156 + 99157 X 3
68-82 (1 hr. 8 min. - 1 hr. 22 < 5 years 99151 + 99153 X 4 99155 + 99157 X 4
min.) 5 years or older 99152 + 99153 X 4 99156 + 99157 X 4
< 5 years As Appropriate As Appropriate
83 or longer (1 hr. 23 min. - etc.)
5 years or older As Appropriate As Appropriate

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 12
 Moderate Sedation

 Procedure: Moderate Sedation

 8 year old male presents after a fall on outstretched right hand.

 Consent: Consent obtained:

 Risks discussed: Nausea, vomiting, inadequate sedation and allergic reaction

 Indications: Sedation purpose: Fracture reduction Procedure necessitating sedation performed by: Different
physician

 Reassessment: Patient reassessed immediately prior to procedure

 Reviewed: vital signs, Verified: bag valve mask available, emergency equipment available, intubation equipment
available, IV patency confirmed, oxygen available and suction available

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 13
 Moderate Sedation
 Sedation start time: 3/13/2016 1:40 AM

 Preoxygenation: Nasal cannula

 Sedation: Ketamine

 Sedation end time: 3/13/2016 3:20 AM

 Total sedation time (minutes): 40

 Post-procedure details:

 Attendance: Constant attendance by certified staff until patient recovered

 Recovery: Patient returned to pre-procedure baseline

 Patient tolerance: Tolerated well, no immediate complications

 Answer: 99156, 99157, 99157

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 14
 Fractures
 A fracture is a broken bone.

 A bone may be completely fractured or partially fractured in any number of ways (crosswise, lengthwise, in multiple
pieces)
 The main symptom is pain. There may also be loss of
functionality depending on the area affected
 Most fractures are diagnosed by using an X-ray, CT, MRI
 Treatment often involves resetting the bone in place
and immobilising it in a cast or splint to give it time to
heal
 In order to code for fracture care services the ED
Physician must provide either “definitive” or
“restorative care."
Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 15
 Fractures

 Definitions of fractures

 Traumatic – A break in the bone usually due to traumatic injury

 Pathologic – Caused by benign bone cysts, malignancy, infection, or select metabolic abnormalities

 Stress -- Occur when bones develop “fatigue” from repetitive forces (Metatarsal most common)

 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

 Displaced -- The bone breaks into separate pieces that move and no longer line up

 Non-Displaced -- A crack is present in a bone but there has been no loss of alignment or displacement of the
bone

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 16
 Fractures

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 17
 Fractures

 Types of fractures

 Stress Fracture  Comminuted Fracture

 Avulsed Fracture
 Linear Fracture
 Impacted Fracture
 Compression Fracture
 Segmental Fracture
 Compacted Fracture
 Simple Fracture
 Torus Fracture
 Transverse Fracture
 Buckled Fracture  Spiral Fracture
 Depressed Fracture  Greenstick Fracture

 Elevated Fracture

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 18
 Fractures

 Fracture Diagnosis:
 X-ray: X-ray imaging produces a picture of internal tissues, bones, and
organs
 Magnetic resonance imaging (MRI): An MRI is a procedure that produces a
more detailed image. It is usually used for smaller fractures or stress
fractures
 Bone scan: An agent is injected that binds in the area of the fracture
where bone turnover is higher than normal
 Computed tomography scan (CT, or CAT scan): a three-dimensional
imaging procedure that uses a combination of X-rays and computer
technology to produce slices, (cross-sectional images), horizontally and
vertically, of the body

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 19
 Fractures
 Spatial relationship between fracture fragments

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 20
 Fracture Care

 Treatment types

 Closed treatment specifically means that the fracture site is not surgically opened (exposed to the external
environment and directly visualized)

 The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation
(reduction) and stabilization (fixation or immobilization)

 Without manipulation

 With manipulation

 With or without traction

 Closed treatment is the most common fracture care in ED

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 21
 Fracture Care

 Manipulation is used throughout the musculoskeletal fracture and dislocation subsections to specifically mean the
attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the
application of manually applied forces.

 Skeletal traction is the application of a force (distracting or traction force) to a limb segment through a wire, pin,
screw, or clamp that is attached (e.g., penetrates) to bone.

 Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied directly to skin only.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 22
 Fracture Care

 Open treatment is used when the fractured bone is either:

 (1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal
fixation may be used; or
 (2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the
fracture site (the fracture site is not opened and visualized)

 External fixation is the usage of skeletal pins plus an attaching mechanism/device used for temporary or definitive
treatment of acute or chronic bony deformity

 Open and percutaneous fixation fracture treatments usually not provided in ED

 Open treatment and/or skeletal fixation are generally performed in the Operating Room

 The type of fracture (e.g., open, compound, closed) does not have any coding correlation with the type of treatment
(e.g., closed, open, or percutaneous) provided

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 23
 Fracture Care

 Types of Fracture Care

 There are two types of fracture care provided in the ED:
 Definitive Care (Non-Manipulative Care)
 Restorative Care (Manipulative Care)

 Definitive Care: 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.

 The patient is provided pain management and the fracture is stabilized by immobilization.

 Usually, small bone fractures that are not displaced (or are minimally displaced) are provided definitive care in the
ED.

 Definitive care also may be provided for long bone fractures with no or little displacement.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 24
 Fracture Care

 Definitive Care Example: A 28-year-old male slips in the bathroom

striking the right side of his left hand on the edge of the tub. An x-ray
shows non-displaced fractures of proximal phalangeal shaft fracture
of middle finger. The Emergency Physician treats the patient’s pain,
reviews expected progression of symptoms, healing, potential for
complications, and placed the finger in a splint. The patient is
ultimately discharged with a prescription for narcotics.

 The Emergency Physician did not perform a manipulation of the

bones therefore a manipulation. However, the care provided was the
same care that a “specialist” would have given, i.e. definitive care
was provided.

 Answer: 26720

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 25
 Fracture Care

 A stable, non-displaced rib fracture is treated by taping and respiratory therapy, such as breathing exercise (braces
or splints are not used because they restrict normal chest expansion and can lead to pulmonary complications).

 A nasal fracture is treated by ice packing and pain medication, and so on.

 Definitive care is reported using CPT codes describing, “Closed treatment of [XYZ] fracture without manipulation.”

 CPT code examples:

 21310 Closed treatment of nasal bone fracture without manipulation

 23500 Closed treatment of clavicular fracture; without manipulation

 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 26
 Fracture Care

 Definitive care can involve treatment of pain, provision of discharge instructions, and in some specific cases,
stabilization of the injury.

 If the patient has a finger fracture and the definitive care that would be provided by the orthopedist is placement of
a finger splint, then in that specific case placement of the splint may represent definitive care and be reported with
the fracture care code.

 However, if the orthopedist would normally place a cast, such as for a distal fibular fracture, but only a splint was
placed in the ED, fracture care would not be reported.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 27
 Fracture Care

 Restorative or Manipulative Care: Displaced fractures are treated with manipulation to restore the bone to the
correct anatomical position.

 The physician uses a combination of manipulative techniques — such as traction, flexion and/or extension, and
medial or lateral rotation — to restore the displaced bony fragments to their original positions, after which the
provider immobilizes the fractured body part using a cast or splint.

 If manipulation of the displaced fragment does not return it to its original anatomical position, the procedure is
considered unsuccessful and the patient is referred a specialist for further care.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 28
 Fracture Care

 Restorative Care Example: A 70-year-old female presents after a fall on an outstretched arm. An x-ray shows a
dorsally displaced distal radius fracture, a “Colles fracture.” The Emergency Physician performs a hematoma block
and reduces the fracture. The physician has performed a manipulation (restorative care). In this case you would
report the code for closed treatment with manipulation of a distal radius fracture

 Answer: 25605

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 29
 Fracture Care

 Helpful chart elements

 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

 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-the counter medications

 Discharge referral or a call for direct referral or transfer of care to the orthopedist or another physician

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 30
 Fracture Care

 What is/are 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

 What is/are not included in fracture care?

 X-ray interpretations are not included in fracture care codes

 The subsequent immobilization (cast, splint, etc.) of the fracture

 Moderate (conscious) sedation should be coded separately when documented

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 31
 Is there a
fracture

Fracture Care
diagnosis?

No Yes

Do not Bill Fracture care Was

manipulation
performed?

Yes No

Bill Closed fracture treatment Was Patient

with manipulation Admitted?

Yes No

Do not Bill Fracture care Is there a

specific follow
up time?
 Fracture care 48 hours Rule:
Yes No

48 hours or Less More than 48 hours Minor Fractures Major Fractures

(Business days) (Business days)

Do not Bill Fracture Bill Fracture care Do not Bill Fracture care
Bill Fracture care
care

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 32
 Fracture Care

 Who Bills for What Services?

 You may report fracture care in the ED only when an ED physician provides the same treatment as a specialist (e.g.,
an orthopaedist).

 If an orthopaedic physician comes to the ED to treat the fracture, the orthopaedic physician (not the ED physician)
reports the fracture care.

 If a patient who receives definitive care in the ED is referred and/or advised to follow up with the specialty physician
(orthopaedist) within three to five days, the fracture care credit goes to the specialty physician because he or she will
provide the complete fracture care (treatment).

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 33
 Fracture Care

 Example: The patient has distal radius fracture. The ED physician applies the splint and advises the patient to follow
up with an orthopaedist immediately. The splint care (29125 Application of short arm splint (forearm to hand); static)
is reported by the ED physician; the fracture care is reported by the orthopaedic physician.

 If a patient who receives definitive care in the ED is referred and/or advised to follow up with the specialty physician
(orthopaedist) in three to five days, the fracture care credit is given to ED provider. This is because the complete
fracture care (treatment) was provided by the ED physician, and follow-up is assumed to be for the next level of
treatment for that fracture.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 34
 Fracture Care

 Example: The patient has a distal radius fracture. The ED physician applies the splint and advises the patient to
follow up with an orthopaedist in three to five days. The ED physician reports the fracture care (25600 Closed
treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of
fracture of ulnar styloid, when performed; without manipulation) with modifier 54 Surgical care only appended.

 If the fracture care code is being reported then a separate splint code should not be added. However, if the ED
physician applies a splint, but does not meet the requirement for definitive or restorative fracture care, then the
splint code would be reported.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 35
 Fracture Care
 For instance, if the patient has a non-displaced distal radius fracture which is placed in a volar short arm splint in
the ED, and the orthopedist will place a cast in several days, then the splint code should be reported.

 Common splinting procedures performed by ED physicians include:

 Finger: 29130

 Short Arm: 29125

 Long Arm: 29105

 Short Leg: 29515

 Long Leg: 29505

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 36
 Fracture Care

 Answer: 25622

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 37
 Dislocation care
 Re-locations of dislocations:

 The ED physician also provides the primary re-location of various dislocated joints

 Examples:

 TMJ

 DP and PIP joints of fingers and toes

 MP joints of hands and feet

 Shoulder

 Nursemaids elbow

 Patellar

 Hip (regular and prosthetic)

 Ankle
Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 38
 Dislocation care

 Treatment:

 Provider must document personal reduction or manipulation of the dislocation/subluxation

 48 -hour rule does not apply to dislocation care codes

 Moderate (conscious) sedation should be coded separately when documented

 Splinting/Strapping included in the dislocation care codes

 E/M level, x-rays, other performed procedures may be billed in addition to dislocation care codes

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 39
 Dislocation care
 Nursemaid Elbow:
 The physician performs closed treatment of
nursemaid elbow in a child with manipulation
 To realign a subluxated (partially dislocated) radial
head, the physician supinates the forearm (palm
upward) while flexing the elbow. No incisions are
made
 If stability of the radial head is questionable, a cast
or splint is applied with the elbow in 90 degrees of
flexion
 24640 Closed treatment of radial head subluxation
in child, nursemaid elbow, with manipulation

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 40
 Fracture and/or Dislocation Care

 Modifiers:

 Append –25 modifier to E/M if fracture and/or dislocation care code has 000 or 010-day global period

 Append –57 modifier to E/M if fracture and/or dislocation care code has 090-day global period

 Some EDs may either have limited orthopedic surgical coverage or have a specific coverage arrangement between
the ED and an orthopedic group, under these arrangements the ED physicians provide the majority of fracture
and/or dislocation manipulations as well as splinting or casting

 In these cases, the follow-up care for the fracture and/or dislocation is provided by the orthopedic doctor after the
majority of fracture and/or dislocation care has been provided by the ED physician. The -54 modifier is required
for these types of cases

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 41
 Fracture and/or Dislocation Care

 Append –54 modifier to fracture care code if fracture and/or dislocation care code has 090-day global period and
follow-up care referred to the orthopedic provider

 Fracture Care Codes “Without” vs. “With Anesthesia”

 The AMA and CPT have stated that the “with anesthesia codes” are to be used in the Operating Room Setting with
general anesthesia.

 These codes do not apply to the ED setting

 Even if Moderate Conscious Sedation or Deep Sedation employed report the “without anesthesia” codes.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 42
 Common Fracture and/or Dislocation care codes in ED
Anatomical Site Fractures Codes
Nasal Bone Fx, w/o manipulation 21310
Nasal Bones and TMJ
TMJ Dislocation, initial or subsequent 21480
Thorax Sternum Fracture 21820-54
Spine (Vertebral Column) Vertebral Process Fracture 22305-54
Clavicular Fx, w/o manipulation 23500-54
Scapular Fx, w/o manipulation 23570-54
Acromioclavicluar dislocation 23540-54
Shoulder dislocation, with manipulation, w/o Anesthesia 23650-54
Shoulder
Shoulder dislocation, with Fx of greater tuberosity, with 23665-54
manipulation
Shoulder dislocation with Fx of surgical or 1 anatomic neck, 23675-54
with manipulation

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 43
 Common Fracture and/or Dislocation care codes in ED
Anatomical Site Fractures Codes
Elbow dislocation, w/o anesthesia 24600
Elbow
Nursemaid's elbow, with manipulation 24640
Metacarpal Fx, single w/o manipulation, each bone 26600-54
Metacarpal Fx, single with manipulation, each bone 26605-54
Phalangeal Fx, shaft, proximal or middle finger or thumb, w/o manipulation 26720-54
Hand / Fingers Phalangeal Fx, with manipulation 26725-54
Phalangeal Fx, distal, finger or thumb, w/o manipulation 26750-54
Phalangeal Fx, distal, finger or thumb, with manipulation 26755-54
Interphalangeal joint dislocation, single, with manipulation, w/o anesthesia 26770-54
Coccygeal Fx 27200-54
Pelvis and Hip Joint Hip dislocation, traumatic, w/o anesthesia 27250-54
Hip arthroplasty dislocation, w/o anesthesia 27265-54

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 44
 Common Fracture and/or Dislocation care codes in ED
Anatomical Site Fractures Codes
Knee dislocation, w/o anesthesia 27550-54
Knee
Patellar dislocation, w/o anesthesia 27560-54
Medial Malleolus Fx, with manipulation 27762-54
Distal fibular Fx, with manipulation 27788-54
Ankle Bi-malleolar ankle Fx, with manipulation 27810-54
Tri-malleolar ankle Fx, with manipulation 27818-54
Ankle dislocation w/o anesthesia 27840-54
Metatarsal Fx, w/o manipulation, each 28470-54
Metatarsal Fx, with manipulation, each 28475-54
Great toe Fx, Phalanax, w/o manipulation 28490-54
Foot and Toes Great toe Fx, Phalanax, with manipulation 28495-54
Other than great toe Fx, Phalanax, w/o manipulation 28510-54
Other than great toe Fx, Phalanax, with manipulation 28515-54

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 45
 Dislocation care

 Answer: 23650

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 46
 Splints

 Splint : 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.

 Types of Splints:

 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).

 Pre-fabricated splints: Pre-fabricated splints are ones that are stored on the shelf and come out of the box ready to
use. It is otherwise known as "Ready made Splint"

 Custom splints: Custom splints orthoses are constructed by hand therapists. They can be made from a
thermoplastic material that is heated in warm water and moulded to custom fit each individual.

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 47
 Splints

 An initial splint and/or strapping service is provided to give patient comfort following contusions, strains, or swelling
post trauma

 Splint application stabilizes a fracture

 Code is assigned if fracture or dislocation codes are NOT billed or coded for

 Coded along with an E/M code

 Pre-fabricated or “off-the-shelf” types of splints should not be coded and billed for any payer class, including self-pay

 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

 CMS and CPT state: “In order to code and bill for a splint, the splint must be created”

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 48
 Splints

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 49
 Splints

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 50
 Splints

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 51
 Splints
Splint Type Splint Type
Boxer splint Custom Stirrup Splint Custom
Ankle stirrup splint (ankle sugar tong) Custom Double Sugar Tong Splint Custom
Radial & Ulnar gutter splint Custom
Long Double Sugar Tong Splint Custom
Long Arm Splint Custom
Thumb Spica Splint Custom
Short Arm Volar Splint Custom
Medial Lateral Splint Custom
Sugar Tong Splint Custom
Long Leg Splint (not prefab knee Custom Dorsal Volar Splint Custom
immobilizer) Coaptation Splint Custom
Posterior Ankle Splint Custom
Swede Brace Splint Custom
Posterior Elbow Splint Custom
Durabracer/3Dwalker/ equalizer boot Custom
Plaster Splint Custom
Figure 8 thumb Splint Custom
OCL (plaster) Splint Custom
Orthoglass (fiberglass) Splint Custom Jones Dressing/Bulky Jones Custom

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 52
 Splints
Splint Type

Cock-up Splint Custom or Pre-Fabricated

Cock-up Splint Custom or Pre-Fabricated

Volar Finger Splint Pre-Fabricated

Knee immobilizer Pre-Fabricated

Air cast /Air splint Pre-Fabricated

Hard Shoe Pre-Fabricated

Bledsoe Brace Pre-Fabricated

Posterior Knee Splint Pre-Fabricated

Aluminium Knee Splint Pre-Fabricated

Aluminium Finger Splint Pre-Fabricated

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 53
 Splints

 Answer: 29515

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 54
 QUESTION TIME

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. | 55
 References

 American Medical Association(AMA) Current Procedural Terminology (CPT)

 AMA CPT Assistant
 BSA Healthcare Advisory
 ICD-10-CM
 Merck Manual of Diagnosis and Therapy

Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. |
Confidential and proprietary. No part maybe circulated, quoted or reproduced without prior approval of Omega Healthcare. |