Multiple Fractures: One code or multiple?

Question:

Our new hand surgeon evaluated a patient with a base of the fifth metacarpal fracture and distal radius fracture. Both fractures were non displaced and the hand surgeon applied a short arm cast.   The hand surgeon submitted two CPT codes, one for the metacarpal fracture and one for the distal radius fracture.  We told the surgeon that only one CPT code may be reported because a single cast was applied.  The surgeon is in total disagreement and asked we reach out to KZA. Who is right?

Answer:

Thanks for your confidence in KZA to answer your coding dilemmas!  The answer is “It depends” on payor rules.

The surgeon is correct according to CPT rules.  Each fracture that is evaluated and treated and meets a global fracture code is reportable assuming unbundling is not occurring. In the scenario presented, there is no overlap between the two anatomic fractures and both global fractures codes, for example, 25600 and 26600 (assuming these codes define the fracture) are reportable.

But wait….

You may be correct if the payor is Medicare and hence the confusion sets in.   The Center for Medicare and Medicaid Services (CMS) via the National Correct Coding Initiatives (NCCI) published Medicare payment rules forPart B Medicare.  In your scenario,  the NCCI edits state, “If multiple dislocations and/or fractures are treated without manipulation and stabilized with a single cast, strapping, or splint, only one CPT code for closed dislocation or fracture treatment (without manipulation) may be reported.”

Your answer is correct if the payor is Medicare; the surgeons’ answer is correct if the payor follows CPT rules.   To ensure accurate reporting, report the surgical CPT codes according to the AMA CPT rules; apply payor rules appropriately based (e.g., Medicare NCCI payment rules are applied for Medicare Part B beneficiaries; private payor rules will vary based on contractual agreements).

Dr. Hand reports two CPT codes to non-Medicare patients for the non-manipulative treatment of the metacarpal and distal radius fractures.

Dr. Hand reports one CPT code if this patient was Granny, who has Medicare Part B coverage.

*This response is based on the best information available as of 06/08/17.