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ED Fracture Care Redux

Set the record straight when reporting global fracture care.

By Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR, Robin Zink, CPC, and Barbara Fontaine, CPC
In the January issue of Healthcare Business Monthly, the article “Tricky ED Fracture Care Billing Explained” (pages 24-26) failed to provide all of the official documentation and sources regarding when to report a global fracture care CPT® code. Let’s clarify who should report a global fracture CPT® code and when.
Set the Record Straight
As coders, billers, administrators, providers, etc., it’s our job to know our various carrier and payer policies, and to follow them correctly. CPT® global fracture care codes have evolved over recent years, creating billing uncertainty. To make matters more confusing, CPT®, the Centers for Medicare & Medicaid Services (CMS), and private payer policies are not necessarily simpatico.
CMS, CPT®, the American Academy of Orthopaedic Surgeons (AAOS), and the American College of Emergency Physicians (ACEP) agree that an emergency department (ED) physician should not report a global fracture care code unless two situations occur:

  1. The ED physician is performing a “restorative” treatment, which has been interpreted to infer performing a reduction/manipulation of the fracture — not simply applying a splint/cast/brace; or
  2. The ED physician will be providing the global package to this patient, meaning he or she will provide follow up during the post-op period.

If these two situations are not present, the ED physician should only report the appropriate evaluation and management (E/M) CPT® code, and possibly the application of a cast/splint, if performed. No official source specifies the length of time between the ED visit and the follow-up care as a determining value for reporting a global code.
Learn by Example
CPT® Assistant, February 1996, provides this example:
Clinical vignette: Patient A presents to the emergency department after falling off a ladder. The emergency department physician determines that the patient’s left forearm is fractured. The physician then applies a short arm cast or splint and instructs the patient to follow up with an orthopedic physician.
To code the emergency department physician’s procedures for patient A, start with the two questions:

  1. Has the ED physician performed any restorative treatment or procedure(s) or is he or she expected to perform any restorative treatment or procedure(s)?
  2. Will the ED physician assume all subsequent fracture care?

In the case of Patient A, the answer to both questions is no. The emergency department physician is responsible only for the initial service of casting or splinting the fractured arm. He or she will not perform, and does not expect to perform, any restorative treatment. In addition, he or she will not assume all subsequent fracture care and has instructed the patient to follow up with an orthopedic physician.
Therefore, the emergency department physician reports code 29075 or 29125 for the application of the initial cast or splint. If the key components for the Evaluation and Management (E/M) codes are met, then also report the appropriate level of E/M with the 25 modifier appended.
CPT® Assistant, April 2002, provides another example:
ED physician evaluates a patient with ankle pain, confirms fracture but due to swelling applies a cast, and refers patient to orthopedic surgeon for treatment and follow-up care.
Does the patient’s condition require restorative treatment/procedure? YES
Will the same physician assume subsequent treatment and follow-up care? NO
The orthopedic surgeon evaluates the patient, reduces the fracture, applies a cast, and instructs the patient to return for follow-up care.
Does the patient’s condition require restorative treatment/procedure? YES
Will the same physician assume subsequent treatment and follow-up care? YES

Physician Service Modifier
ED Appropriate ED visit 25
ED Appropriate cast/strapping
OS Appropriate restorative treatment/procedure service (E/M and casting included in service)

The AMA also provides this example:
The ED physician sees a patient with a displaced Colles’ fracture. The ED physician performs a closed reduction to reduce the displacement and align the fracture, then applies a cast. She makes a referral for the patient to follow up with his family provider or orthopedic surgeon.
Does the patient’s condition require restorative treatment/procedure? YES
Was the restorative treatment/procedure performed by this provider? YES
Will the same physician assume subsequent treatment and follow-up care? NO
In this case, the ED physician did provide a restorative treatment/reduction/manipulation, and she should report the appropriate CPT® code (e.g., 25605 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation), with modifier 54 Surgical care only appended because she will not provide the subsequent treatment or follow-up.
Remember this advice from CPT® Assistant, February 1996:
Typically, the role of the emergency department physician is to treat an acute problem and refer the patient to a physician of a different specialty for subsequent treatment. In most cases, the emergency department physician will be responsible only for the initial care of a fracture that does not require immediate surgery (i.e., application of the first cast/strapping). The patient is then generally referred to an orthopedic physician for all subsequent fracture, dislocation, or injury care.
View the ACEP coding guidance for procedures in the ED.
For Medicare coverage policy on global periods, see the Medicare Claims Processing Manual, Pub. 100-04, chapter 12, section 40.

Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR, has 30-plus years’ experience in the healthcare arena, from nurse’s aide to ward clerk and medical transcriptionist, to office manager. More than 25 of those years were spent in orthopaedics. Vaught stays current by attending the annual conventions for BONES, AAPC, MGMA, and AMA’s CPT® symposium. She also has provided testimony regarding correct coding issues and compliance in fraud and abuse cases. Vaught is a member of the Olympia, Washington, local chapter.
Robin Zink, CPC, has 34 years’ experience in the healthcare industry, having worked in various capacities in physician practice and hospital settings. Zink is the business office manager at Lancaster Orthopedic Group, where she has worked for the past 16 years. Her areas of expertise include revenue cycle management, coding, and regulatory compliance. Zink is a member of the Lancaster, Pennsylvania, local chapter.
Barbara Fontaine, CPC, has worked in medical offices for 30 years — the past 14 at Mid County Orthopaedic Surgery and Sports Medicine in St. Louis, Missouri. She serves as chair on the AAPC Chapter Association board. Fontaine is a member of the St. Louis West, Missouri, local chapter.

Evaluation and Management – CEMC

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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