Billing Fractures in the ED

Billing Fractures in the ED

Look at what kind of fracture it is, then decide whether it’s restorative or definitive care.

By Jeannie Dean, CPC, COC, CPMA, CEMA, CEDC, CPC-I
There is a common misconception that you cannot bill for fracture care in the emergency department (ED). In fact, emergency physicians regularly provide fracture care. To determine if fracture care can be billed in the ED, you must decide if the emergency physician is providing restorative care (manipulation) or definitive care (e.g., a splint or the same care an orthopedist would provide).

Restorative Care

Common fractures presented in the ED that require manipulation include:

  • Finger fractures
  • Toe fractures
  • Metacarpal fractures
  • Distal fibular fractures
  • Bimalleolar and trimalleolar ankle fractures
  • Distal radius fractures

It’s important for physicians to provide a procedure note to ensure coders can bill appropriately for the procedure performed.
Example: A patient presents to the ED with wrist pain. An X-ray reveals a distal radius fracture. The physician reduces the fracture using manipulation (restorative care). In this situation, report the code for closed treatment of a distal radius fracture with manipulation (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).

Definitive Care

Common fractures for which an emergency physician performs definitive care in the ED are:

  • Finger fractures
  • Toe fractures
  • Clavicle fractures

One fracture code that is frequently — and mistakenly — not billed in the ED is 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each. When a patient has a phalanx fracture, the physician almost always provides definitive care. The emergency physician:

  • Treats the patient’s pain;
  • Reviews all medical documentation;
  • Explains the expected progression of symptoms, healing process, and potential for complications; and
  • Buddy tapes the injured toe together with the toe next to it.

The patient is then discharged home with or without a prescription for pain management.
In the example above, the emergency physician did not perform a type of manipulation but did provide the same treatment a “specialist” would have provided. This qualifies as definitive care, and should be reported using CPT® 28510 for each fractured phalanx treated.
When billing for definitive care, the normal time requested for follow-up is five to seven days. If the patient needs to be seen by a specialist in less than one week, the ED physician most likely provided palliative care, only — not definitive care.

E/M Documentation, Modifier Use

When a patient is seen for a fracture, a detailed exam is commonly required. The physician must check the extent of the injury, neurovascular status, and other injuries. Physicians should document these visits thoroughly. Fracture treatment evaluation and management (E/M) services typically start at a level IV. Because fracture care is considered a major procedure code (i.e., it has a 90-day global period), you must append modifier 57 Decision for surgery to the appropriate E/M procedure code reported at the same time as the fracture care.
When the emergency physician provides fracture care and the patient requires follow up by a specialist, append modifier 54 Surgical care, only to the CPT® code being billed. This modifier lets the payer know the preoperative and operative care were provided in the ED and the postoperative care will be handled elsewhere. When using modifier 54, the ED physician typically receives 70 percent of the revenue associated with the fracture care service.

Jeannie Dean, CPC, COC, CPMA, CEMA, CEDC, CPC-I, has more than 20 years’ experience in health information management. She provides coding, compliance, physician documentation, and revenue cycle management services to specialty physician practice management organizations and private practices, and she speaks for MRI and other organizations. Dean is a member of the Memphis, Tenn., local chapter. She can be reached at

Medical coding books

No Responses to “Billing Fractures in the ED”

  1. Laurence Kempton says:

    The important question is not whether ED physicians “can” bill for fracture care. I agree the ED physicians have the ability to bill for fracture care while following coding guidelines that you described. The important question is a whether it is ethical for ED physicians to bill for fracture care. ED physicians do not have the knowledge base to know what fractures need surgery. The intent of fracture care billing is to definitively treat a fracture nonsurgically, and the process of shared decision making between the physician and patient requires that informed consent is obtained from the patient. Unless an ED physician can discuss with the patient all treatment options and the associated risks and benefits, he or she cannot obtain informed consent for fracture care and cannot know whether or not fracture care is appropriate definitive treatment. Definitive treatment is not determined and administered until the patient is evaluated by the person that knows what definitive treatment will be.
    In the distal radius fracture example that you provide, if the surgeon to whom the patient is referred provides surgical care, then the patient is getting billed for two definitive treatments. That is inappropriate. I am not referring to a scenario in which the patient fails nonsurgical management because the fracture displaces and then gets surgical treatment with a 58 modifier. I am referring to a fracture for which the surgeon would have recommended surgery from the start.
    Consider another scenario: An orthopaedic surgeon sees a patient with an intertrochanteric femur fracture on day 1, adjusts the position of the leg to improve patient comfort and fracture alignment, and documents and codes for E&M with a 57 modifier and closed treatment with manipulation. Documentation is done to support this coding, and payors will go along with it. The next day, the surgeon surgically treats the fracture, documents appropriately, and codes the surgical treatment with a 58 modifier. This patient was inappropriately billed for two definitive treatments of the same fracture. In this scenario similar to the distal radius fracture example, the treating physician documented and coded for fracture care with the sole rationale that it follows documentation and coding guidelines. However, being allowed to do something does not make it ethical.
    Unless an ED physician is able to obtain informed consent for definitive treatment, then the ED physician should not code/bill for definitive treatment.