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Demographic and Financial Implications of Pediatric Emergency Department Fracture Manipulation

Ward, W. Timothy MD; Rihn, Jeffrey A. MD

Journal of Pediatric Orthopaedics: December 2007 - Volume 27 - Issue 8 - p 877-881
doi: 10.1097/BPO.0b013e3181558c4d
Trauma: Original Article

Background: The demographic features, work relative value units (WRVUs), and financial implications of pediatric emergency department (ED) manipulative fracture treatment are presented. The aims of this study are to quantify these parameters and gauge their impact on lifestyle and reimbursement.

Methods: All ED fracture reductions performed by orthopaedic residents in a children's hospital for fiscal year 2004 were grouped by month, day, time, anatomical location, and payer mix. Work relative value units and reimbursement were assigned for each fracture, contrasting the use of global current procedural terminology manipulation facture codes to the actual use of global current procedural terminology nonmanipulation codes first generated when the child presented to the senior staff office.

Results: Three hundred seventy-five fractures were manipulated in the ED. Eighty-one manipulations were done on Saturday and 61 on Sunday compared with an average of 47 for the other 5 days. Nineteen percent of manipulations were performed between 7 am and 6 pm, 37% between 6 and 11 pm, and 44% between 11 pm and 7 am. Sixty-nine percent of the children had private insurance, 29% had Medicaid, and 2% had no medical coverage. Potentially 2358 WRVUs could have been recorded had senior staff been present for the reduction in the ED compared with the actual total of 1168 WRVUs recorded in the office a few days later. Using a proxy model of 100% Western Pennsylvania Medicare coverage for these fractures, $179,754 of reimbursement was available with manipulation included compared with $106,010 without manipulation. For our actual payer mix, manipulation would have contributed a 37% increase to fracture care margin for these 375 fractures but would have only provided a 2.5% increase to overall pediatric orthopaedic revenue production for fiscal year 2004.

Conclusions: The component of reimbursement resulting from manipulation contributed significantly to fracture care margin for those fractures requiring manipulation but did not have a significant impact on overall pediatric orthopaedic revenue production. The added senior staff work effort required to gain the manipulation reimbursement component of fracture care in the ED is substantial considering the small contribution to overall revenue.

Clinical Relevance: Alternative mechanisms of compensation should be devised if the goal is to offer financial incentive to senior staff for their availability for all fracture manipulations in the ED.

From the Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA.

None of the authors received financial support for this study.

Reprints: W. Timothy Ward, MD, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.