Tricky ED Fracture Care Billing Explained
Different emergency circumstances can manipulate who should bill for what services.
By Samson Kumaraswamy, BPT, MSc, CPC, CEDC
Coding for fracture care in the emergency department (ED) can be challenging. Here are the basics you’ll need to know to rise to its challenges.
Determine the Type of Fracture Care
There are two types of fracture care provided in the ED: definitive care (non-manipulative care) and restorative care (manipulative care).
The patient is provided pain management and the fracture is stabilized by immobilization. Usually, small bone fractures that are not displaced (or are minimally displaced) are provided definitive care in the ED. Definitive care also may be provided for long bone fractures with no or little displacement.
For example, a phalangeal fracture is treated by placing the finger in a splint or by buddy taping. A stable, non-displaced rib fracture is treated by taping and respiratory therapy, such as breathing exercise (braces or splints are not used because they restrict normal chest expansion and can lead to pulmonary complications). A nasal fracture is treated by ice packing and pain medication, and so on.
Definitive care is reported using CPT® codes describing, “Closed treatment of [XYZ] fracture without manipulation.”
CPT® code examples:
21310 Closed treatment of nasal bone fracture without manipulation
23500 Closed treatment of clavicular fracture; without manipulation
26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each
28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each
Note: Last year, 21800 Closed treatment of rib fracture, uncomplicated, each would’ve been on this list, but this code is deleted for 2015. Per the CPT® 2015 codebook, “To report closed treatment of an uncomplicated rib fracture, use the Evaluation and Management codes.”
Restorative or Manipulative Care
Displaced fractures are treated with manipulation to restore the bone to the correct anatomical position. The physician uses a combination of manipulative techniques — such as traction, flexion and/or extension, and medial or lateral rotation — to restore the displaced bony fragments to their original positions, after which the provider immobilizes the fractured body part using a cast or splint.
If manipulation of the displaced fragment does not return it to its original anatomical position, the procedure is considered unsuccessful and the patient is referred a specialist for further care.
Restorative care is reported using CPT® codes describing, “Closed treatment of [XYZ] fracture with manipulation.”
CPT® code examples:
26605 Closed treatment of metacarpal fracture, single; with manipulation, each bone
26725 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each
27762 Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction
28435 Closed treatment of talus fracture; with manipulation
28515 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each
Who Bills for What Services?
You may report fracture care in the ED only when an ED physician (or other qualified healthcare professional) provides the same treatment as a specialist (e.g., an orthopaedist). If an orthopaedic physician comes to the ED to treat the fracture, the orthopaedic physician (not the ED physician) reports the fracture care.
If a patient who receives definitive care in the ED is referred and/or advised to follow up with the specialty physician (orthopaedist) within three to five days, the fracture care credit goes to the specialty physician because he or she will provide the complete fracture care (treatment).
The patient has distal radius fracture. The ED physician applies the splint and advises the patient to follow up with an orthopaedist immediately. The splint care (29125 Application of short arm splint (forearm to hand); static) is reported by the ED physician; the fracture care is reported by the orthopaedic physician.
If a patient who receives definitive care in the ED is referred and/or advised to follow up with the specialty physician (orthopaedist) in three to five days, the fracture care credit is given to ED provider. This is because the complete fracture care (treatment) was provided by the ED physician, and follow-up is assumed to be for the next level of treatment for that fracture.
The patient has a distal radius fracture. The ED physician applies the splint and advises the patient to follow up with an orthopaedist in three to five days. The ED physician reports the fracture care (25600 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) with modifier 54 Surgical care only appended.
Fracture Care Points to Remember
There are several additional points to consider when reporting fracture care in the ED. Consider the following (courtesy of CGS Medicare):
Source: CGS Medicare, “Billing for Fracture Care: Emergency Department vs. Physician/Orthopedic Office,” www.cgsmedicare.com/partb/pubs/news/2013/0513/cope22035.html
- “Global fracture care” includes treating the fracture and providing necessary follow-up care (e.g., performing and accepting restorative care and follow-up treatment of the fracture until healed).
- To submit a claim for fracture care, the treatment must meet the definition of “restorative” care and must involve more than merely splinting the fracture after straightening the limb. Physicians who treat a fracture and provide a significant portion of the global fracture care may submit the appropriate CPT® code for treating the fracture and be reimbursed for the global surgical package of care.
- ED physicians (and non-physician practitioners authorized to provide emergency room services) who treat the fracture (as described in the second bullet) but do not provide follow-up care may submit a claim for the fracture treatment code with CPT® modifier 54.
The patient has a metacarpal displaced fracture. The ED physician manipulates and reduces the fracture and applies a splint. This should be coded 26605-54.
- A non-ED physician, such as an orthopaedic surgeon, who provides casting, follow-up evaluation and management (E/M) of the fracture until healed, may submit a claim for the fracture treatment code with CPT® modifier 55 Postoperative management only.
The patient has a metacarpal fracture and is provided treatment in the ED. The same patient follows up with an orthopaedist, who provides the casting and splinting, and treats the patient until the fracture heals. The ED physician will report 26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone-54, while the orthopaedist will report 26600-55.
Samson Kumaraswamy, BPT, MSc, CPC, CEDC, is a physical therapist working in medical coding for over eight years, primarily in ER coding. He works as client relationship manager in coding, auditing, and training operations at Global Healthcare Resource.