Fracture Care Coding Guidelines

Fracture Care Coding Guidelines (2023)

By Mary LeGrand, RN, MA, CCS-P, CPC; Margaret Maley, BSN, MS; Robert H. Haralson III, MD, MBA; M. Bradford Henley, MD, MBA; Matthew Twetten, MA

Fracture care coding guidelines CMS is controversial; this article suggests coding for this treatment. Closed treatments are either with or without manipulation.

An orthopedic surgeon has the following two ways of coding closed treatment of a fracture under Current Procedural Terminology (CPT):

“Global” reporting of the services by using the 90-day, global fracture code with or without reporting the initial evaluation and management (E&M) service that resulted in the decision for closed treatment, or “Itemized” reporting of the services by reporting each patient encounter separately. The physician reports each service independently and does not enter into a 90-day global period. The AAOS position is that the orthopaedist must have the option of coding these services, either way, to enable the treating surgeon to address the specific situation and to meet the physician’s contractual obligations with payors.

Charging a single, all-inclusive large global fee may seem excessive to a patient, especially if the patient doesn’t understand that the charge includes 90 days of physician E&M services related to the fracture. Other times, insurance companies may pay for emergency visits (for example, a global fee with limited patient financial responsibility) but may not pay for office visits, or vice versa. Some insurers require high copayments for office visits, while others apply coinsurance to the global fracture service. In these situations, a patient may express concern about the financial cost of one method or the other. The physician should report the method that best addresses the situation, meets the physician’s contractual obligations, and complies with coding rules.

The Centers for Medicare and Medicaid Services (CMS) does not have a preference for coding closed nonmanipulative fracture services. Processing a single global claim for 90 days of care may be less expensive for the government, insurance companies, and physician offices than submitting and processing multiple claims (during 90 days of fracture care) and adjudicating disputes resulting from appeals to claim denials.

Because CMS does not give coding advice, it has not given specific directions for reporting closed treatment of fractures. In 2003, however, CMS issued a directive about adjudication of claims stating that carriers would not allow the total compensation for fragmented (e.g., itemized) coding to exceed the total compensation for comparable global coding.

In recent years, CMS carriers (such as Rhode Island and Kentucky) have also asked for a refund when investigating a patient complaint resulting from a large financial responsibility after a physician had charged for nonmanipulative fracture “surgery.”

How To Use The Global Method/Period

When using the global method, code for the procedure, which invokes a 90-day global period. The global fee and the application of the first cast or splint cover all subsequent E&M services related to the fracture. Depending on the encounter level, the original E&M service may be coded with a modifier (such as 57 or 25). If the encounter is minimal, which may be for evaluation of an isolated injury, do not code for the encounter. Many payors will not pay for an encounter code in this situation.

When using the itemized method, report the initial services by the physician or nonphysician provider (physician assistant, nurse practitioner, or clinical nurse specialist) with the appropriate codes as follows:

E&M for the first visit—9920x-25 for a new patient office visit, 9921x-25 for an established patient office visit, or 9924x-25 for a consultation provided in the emergency department (ED) or in the physician’s office.

Modifier 25 must show that the E&M service is significant and separately identifiable because it is associated with a procedure (application of a cast or splint). If the service is provided in a setting other than the office or ED, report the appropriate category and level based on the place of service and append modifier 25.

Application of an initial cast or splint (assuming that the physician or supervised staff employed by or under contract to the physician applies the cast or splint)

Supplies for casting/splinting, if applicable, depending on the place of service

Subsequent services are reported as follows:

E&M services using established patient visit codes if the services are provided in the office (9921x), or other E&M code that is specific to the service setting

Application of replacement cast(s) or splint(s), assuming the physician or supervised employed or contracted staff applies the cast or splint). Add modifier 25 to the appropriate E&M code if it is a “significant and separate service” provided in addition to the procedural service (such as application of the cast/splint).

Supplies, if applicable, depending on the place of service

When is the closed treatment of fractures reported?

Closed treatment of fractures is commonly reported in two scenarios. One is when the injury requiring nonmanipulative treatment is the physician’s only procedural service.

As these examples show, reimbursement is about the same, but different methods are advantageous for different situations. Itemized reporting requires the physician to have supporting documentation and medical necessity for the E&M service at each subsequent visit.

No specific E&M documentation is required for subsequent visits when fractures are reported using the global fracture codes. The orthopaedic surgeon should have the flexibility to change how fracture care is coded to allow what is best for the patient and society.

Closed treatment of fractures may also be reported within the global period of another procedural or surgical treatment (for example, during the same hospitalization as the open treatment of another fracture or injury, such as anterior cruciate ligament [ACL] repair). This commonly occurs when a patient has sustained multiple injuries, fractures, or a new fracture within the global period of prior service (the patient slipped and fell while using crutches after an ACL repair).

Situations involving the closed treatments of fractures that occur concurrently or within the global period of another procedure or surgical treatment most commonly arise when caring for patients with multiple injuries, one of which is a fracture requiring a closed treatment.

Reporting by an ED physician

Another problem in reporting the Fracture care coding guidelines CMS is how an ED physician should code for nonmanipulative fracture care when he or she was the only physician who saw the patient in the ED.

The ED physician has occasionally used a global fracture care code to apply a splint/cast, and then referred the patient to an orthopaedist for follow-up care. In such a situation, the orthopaedist cannot receive reimbursement for the care provided.

CPT suggests that only the physician who provides the “restorative” treatment and is “responsible for the initial cast, follow-up evaluation(s) and the management of the fracture until healed” should use the global code. The proper coding is for the ED physician to code for the ED visit and apply a splint if appropriate.

If manipulative fracture care that meets the definition of “restorative treatment” is provided by an ED physician and the ED physician has provided a “significant portion of the global fracture care,” the ED physician may use the global code with modifier 54 (surgical care only). However, this treatment must meet the “restorative” care definition and should not be merely splinting a fracture after straightening the limb.

According to CPT, the following reference supports reporting the services using an E&M code and the appropriate cast/splint application code. “If cast application or strapping is provided as an initial service (e.g., the casting of a sprained ankle or knee) in which no other procedure or treatment (e.g., surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code (99070) in addition to an evaluation and management code as appropriate.” Supplies would be reported using the appropriate A (nonMedicare) or Q (Medicare and other payors requiring Q) codes.

Mary LeGrand, RN, MA, CCS-P, CPC, and Margaret Maley, BSN, MS, are consultants with KarenZupko & Associates. Robert H. Haralson III, MD, MBA, is AAOS director of medical affairs. M. Bradford Henley, MD, MBA, is a member of the AAOS Coding, Coverage, and Reimbursement Committee; Matthew Twetten, MA, is a senior policy analyst in the AAOS department of health policy and governance initiatives.

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