APMA News - May/June 2017 - 58

Reimbursement

CMS Payment of a Single Metatarsal Fracture When the
Doctor Treats Multiple Closed Metatarsal Fractures
An opinion piece by Harry Goldsmith, DPM, CEO of Codingline and APMA consultant
biguous. The word "each" means, well, each-referring to every
one of two or more things, regarded and identified separately.
The NCCI/CMS, ignoring the CPT code description, set the
MUE (Medically Unlikely Edits) at "2" (one unit for the right
foot and one unit for the left foot). So, if your Medicare patient
falls off a ladder and fractures three metatarsals (nondisplaced),
your treatment with the initial immobilization and follow-up is
15. When a fracture or dislocation is repaired, only one fracvalued by Medicare to be a single treatment of closed fracture.
ture/dislocation repair code may be reported. Closed repair
The problem with having multiple metatarsal fractures in a foot
codes, percutaneous repair codes, and open repair codes for
is that each fracture is unique, and may demonstrate that
the same anatomic site are
uniqueness in how they each
mutually exclusive of one
heal over the 90-day global peIf CMS doesn't see the value
another, and only one of
riod. One fracture might heal
without any problems; one
these codes may be reportin reimbursing each fracture
ed for the repair of a fracfracture might have a delayed
treatment, then CMS should request
ture or dislocation at an
healing; and one fracture might
a change in the CPT language.
anatomic site.
go onto nonunion. Is it fair?
No. If CMS doesn't see the valWhat they shouldn't do is unilaterally
16. If a single cast, strapue in reimbursing each fracture
ignore the CPT description.
ping, or splint treats multitreatment, then CMS should
ple closed fractures withrequest a change in the CPT
out manipulation, only one closed fracture treatment
language. What they shouldn't do is unilaterally ignore the CPT
without manipulation CPT code may be reported. Additiondescription. Fortunately, most non-Medicare payers continue to
ally, if a single cast, strapping, or splint treats multiple fracfollow the standard descriptions of CPT codes.
tures without manipulation in addition to one or more fracTo review NCCI guidelines, go to the APMA Coding Reture(s) with manipulation, a closed fracture without
source Center (www.apmacodingrc.org), log in, click on the
manipulation CPT code should not be reported separately.
"CCI" tab, and click on "Documentation Library." The entire set
These policies also apply to the closed treatment of multiple
of guidelines, chapter by chapter, corresponding to CPT coding,
fractures not requiring application of a cast, strapping, or
is available there.
splint. Thus, if multiple closed fractures occur in an area
All APMA Coding Resource Center (CRC) subscribers rethat would have been treated with a single cast, strapping,
ceive complimentary access to CodinglineSILVER, which inor splint, only one CPT code for closed fracture treatment
cludes an easily searchable archive of more than 30,000 codwithout manipulation may be reported. If a cast, strapping,
ing questions, and subscribers can ask foot and ankle coding,
or splint applied after an open or percutaneous treatment of
reimbursement, and practice management questions through
a fracture also treats a closed fracture without manipulaCodinglineSILVER's interactive foot and ankle forum. Current
tion, a closed fracture without manipulation CPT code
CRC subscribers can use CodinglineSilver's archive and forum
should not be reported separately. These principles also apby logging on to www.apmacodingrc.org and clicking on the
ply to the treatment of multiple dislocations or combinations
Codingline tab.
of multiple closed fractures and dislocations...
To subscribe to the CRC today, go to www.apmacodingrc.
org. For a test drive, click on "7-Day Free Trial."
n
What we have is a CMS-made coding issue, where the official CPT 28470 code description differs from the selective interContact the APMA Health Policy and Practice
pretation by CMS of the CPT code. While payers do interpret
Committee at healthpolicy.hpp@apma.org.
codes when there is some ambiguity, the word "each" is not am-

Over the past several months, Codingline has received questions on its interactive foot and ankle forum about CPT 28470.
CPT describes CPT 28470 as "closed treatment of metatarsal
fracture; without manipulation, each." [emphasis added]
The National Correct Coding Initiative (NCCI) (CMS/Medicare), however, notes in its guideline:

58 APMA News May/June 2017

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Table of Contents for the Digital Edition of APMA News - May/June 2017