Q. We had a patient come in with an open fracture of the distal interphalangeal joint of the right index and middle fingers, ICD-9 [International Classification of Diseases, 9th Revision, Clinical Modification] code 816.12. The provider set and splinted them both. Can I bill procedure code 26765 (“Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each”) twice?

A. A diagnosis of open fracture means that the skin has been broken traumatically, but it does not automatically require open surgical treatment, which is required for Current Procedural Terminology (CPT) code 26765. The terms closed treatment and open treatment in the CPT guidelines have been carefully chosen to accurately reflect the specific orthopedic procedure that is performed.

Closed treatment specifically means that the fracture is not surgically opened (exposed to the external environment and directly visualized). It includes repair with manipulation, repair without manipulation, or repair with or without traction Open treatment means that the surgeon performs an incision to expose the fracture and usually performs internal fixation. Alternatively, the surgeon may insert an intramedullary nail or other orthopedic device for international fixation of the fracture.

In general, during an open fracture treatment, the provider incises the skin over the fractured bone once the patient has been appropriately prepared and anesthetized. The provider dissects down through the subcutaneous tissue and retracts the muscles to obtain adequate exposure of the phalanx fracture. The provider then adjusts the bone to reduce the fractured fragments or to bring the dislocated bones back to their normal alignment. The provider may fix the fracture using implants like a plate, screw, nail, or wire before closing the wound by suturing the skin layers together. An x-ray may be obtained to confirm the reduction of the fracture. The surgeon will place a splint or brace on the digit for protection. Generally, these procedures are performed in an operating room of a hospital or ambulatory surgery center. You must look for these types of notes in the procedure description in order to bill CPT code 26765 correctly.

Almost invariably when fracture treatment is performed in an urgent care center, the biller will encounter closed treatment of the fracture. For finger fractures, one of the following codes will apply:

  • CPT code 26750: “Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each”
  • CPT code 26755: “Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each” for guidance.

If you bill the code twice, you should attach modifier -59 to the second code. Also specify the finger with modifiers F1 through FA:

      • F1: “Left hand, second digit”
      • F2: “Left hand, third digit”
      • F3: “Left hand, fourth digit”
      • F4: “Left hand, fifth digit”
      • F5: “Right hand, thumb”
      • F6: “Right hand, second digit”
      • F7: “Right hand, third digit”
      • F8: “Right hand, fourth digit”
      • F9: “Right hand, fifth digit”
      • FA: “Left hand, thumb”

When billing the codes to insurance, you will use ICD-9 code 816.12, “Open fracture of distal phalanx or phalanges of hand,” to represent both fingers, and you should include modifier F6,
“Right hand, second digit,” on one procedure line and F7, “Right hand, third digit,” on the second procedure line.
Once you have converted to ICD-10 (International Classification of Diseases, 10th Revision, Clinical Modification, required by October 1, 2015), you will be able to identify each fracture with a diagnosis code because of the specificity of the codes. You will be able to include the displacement or nondisplacement, laterality, and visit type (e.g., initial encounter for open fracture, subsequent encounter with routine healing) for each injury:

      • S62.630, “Displaced fracture of distal phalanx of right index finger,” requires a 7th-digit extension that represents the encounter:
        • – A: Initial encounter for closed fracture
        • – B: Initial encounter for open fracture
        • – D: Subsequent encounter for fracture with routine healing
        • – G: Subsequent encounter for fracture with delayed healing
        • – K: Subsequent encounter for fracture with nonunion
        • – P: Subsequent encounter for fracture with malunion
        • – S: Sequelae
        •  S62.632, “Displaced fracture of distal phalanx of right middle finger,” also requires a 7th-digit extension from the preceding list.

Make sure that you link the correct modifiers to the codes that are linked to the finger-specific ICD-10 code (e.g., “open fracture left index finger, closed fracture left middle finger”).

If you were billing using ICD-10, your codes for the visit you describe would be S62.630A and S62.632A. You would report the procedures best described by the documentation for each digit, and link the diagnosis to the corresponding procedure. Check with the payors to determine if they will still require the modifiers on the procedures.

DAVID STERN, MD (Practice Velocity)

Open Fracture Treatment Versus Closed Fracture Treatment

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine