Don’t Break Your Fracture Care Revenue Cycle
Coding thoughts for closed treatment of fractures without manipulation
Coding closed treatment of fractures without manipulation can be a challenge. To ensure your coding results in proper reimbursement for the services rendered, let’s review fracture types, applicable codes, and the work they represent.
Fracture Treatment Isn’t One Size Fits All
When a patient is initially treated for a traumatic fracture, there are four typical methods of care that an orthopedic physician may provide:
- Closed reduction is non-surgical manipulation of a fractured bone to restore the bone to normal anatomic alignment.
- Percutaneous fixation involves the placement of a stabilizing device such as a rod, plate, multiple wires, pins, or screws across a fractured bone, typically under imaging guidance.
- Open reduction with internal fixation (ORIF) is an incisional procedure to realign and fixate separated bone fragments.
- Closed treatment without manipulation involves fitting the patient to appropriate materials for bone stabilization and weight bearing/non-weight bearing function.
Closed Treatment Always Involves a Medical Supply
Closed treatment without manipulation is perhaps the least understood of the common fracture treatment options. When there is no manipulation of a fracture, what constitutes treatment?
Treatment involves the provision and fitting of materials to immobilize a joint and allow for separated bone parts to fuse together, or to serve as a source of support for weight bearing. Examples of such materials are casts, splints, slings, braces, canes, walking boots, and crutches.
If the provider does not stabilize the bone using a medical supply, or does not indicate a plan for follow-up care, the non-operative, non-manipulative fracture care codes cannot be reported. Rather, the provider should report the evaluation and management (E/M) service with no modifier, and an appropriate E/M service code(s) for subsequent, related visits.
Example: A 17-year-old girl was playing soccer at her high school’s athletic field when she slipped on wet grass. Three days later, she saw her physician, who diagnosed a nondisplaced left foot cuboid fracture during a level 3 established patient visit. The doctor fitted her to a custom-fabricated plastic ankle-foot orthosis with ankle joint and told her to follow up with him in two weeks, or sooner if there isn’t relief of the pain.
This is an example of a closed treatment without manipulation. Proper CPT® coding is 28450-LT Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each – Left side and 99213-57 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity – Decision for surgery. Note that because the ankle-foot orthosis was provided in the office, the practice can bill for it separately with L1970 Ankle foot orthosis, plastic with ankle joint, custom fabricated.
Non-operative, Non-manipulative Fracture Care Codes
|Radial shaft (alone)||25500|
|Ulnar shaft (alone)||25530|
|Radial and ulnar shafts||25560|
|Other carpal bone||25630|
|Articular metacarpophalangeal (MCP)/ interphalangeal (IP) joint||26740|
|Posterior pelvic ring||27197|
|Acetabulum (hip socket)||27220|
|Distal femoral condyle||27508|
|Distal femoral epiphyseal separation||27516|
|Proximal tibia (plateau)||27530|
|Distal fibula/lateral malleolus||27786|
|Distal tibia weight bearing articular (WBA) portion||27824|
|Tarsal bone (other)||28450|
|Great toe, phalanx, or phalanges||28490|
|Phalanx or phalanges other than great toe||28510|
Documenting Coding Closed Treatment Without Manipulation
Acceptable documentation for reporting non-surgical/non-manipulative fracture care may include:
|Item Provided||Musculoskeletal Structure|
|Boot/Shoe||Ankle, foot/heel, toe(s)|
|Brace (hinged)||Elbow, thigh, knee, leg (tibia/fibula), ankle/foot/heel|
|Buddy tape||Fingers, toes|
|Cast (short/long/spica)||Arm/hand, wrist, radius, shoulder, elbow, hip, leg, knee, fibula, ankle/ foot/heel/toe|
|Crutch(es)||Ankle, foot, knee, hip|
|Orthosis||AFO, KAFO, CTLSO, etc. (HCPCS Level II E and L codes)|
|Ortho/Surgical shoe||See “Boot/Shoe”|
|Sling||Elbow (24670), shoulder (23520, 23540, 23570)|
|Sneaker/Sandal (soft)||See “Boot/Shoe” (ankle/foot)|
|Splint||Arm/hand/finger, shoulder, elbow, leg, knee, ankle/foot, radius, wrist (L3908)|
|Strapping/Tape||See “Buddy tape”|
|Swath (w/sling)||Humeral shaft (24500)|
|Traction (skeletal)||Arm, shoulder, leg, hip, knee, foot/toe(s)|
|Traction (skin)||Finger/phalangeal shaft/proximal/middle phalanx (26720)|
|Walking boot (Cam)||See “Boot/Shoe”|
Unacceptable, nonspecific documentation, which does not support reporting of non-surgical/non-manipulative fracture care, includes:
- Bed rest
- Dressing change only
- Gait/balance training
- Home exercise program
- Ice (with rest, compression, and elevation)
- Medication prescription (such as for pain control)
- Non-operative/nonsurgical treatment with no elaboration
- Non-weight bearing (NWB) with no elaboration
- Physical therapy
- “Protected” WB
- Walking aid not specified
- Weight bearing as tolerated (WBAT) with no elaboration
Although non-operative, non-manipulative fracture care services are not surgical, they carry a 90-day global period. As such, if an E/M service is provided on the same day as fracture care (which usually is the case), modifier 57 Decision for surgery must be appended to the E/M code. Follow-up visits within the global period (91 days, including the day of treatment) are tracked using 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.
Fracture Care vs. Supply, E/M Billing
There is ongoing debate as to whether it’s better not to report a fracture care code, and instead to bill for the supply and its application plus individual follow-up visits until the fracture is healed. The general consensus is to use the fracture care codes designated as “closed treatment without manipulation” and bill the initial E/M with modifier 57. This more aptly covers the true work of the rendered services with supporting documentation.
It may be a judgment call as to what is the optimum fracture care solution on a case-by-case basis. For instance, orthopedic physicians have suggested that minor digital fractures treated with buddy tape be reported with the multiple visits rather than the fracture care codes because the sum of the relative value units (RVUs) for the multiple visits is typically higher.
It has also been suggested that if fracture care is provided in the emergency room (ER), report it with modifier 54 Surgical care only, and that if the device fitting was performed by an ER doctor, subsequent office visits to the orthopedic practitioner be reported with the fracture care code with modifier 55 Postoperative management only. This method of reporting is questionable because: a) there is no surgical procedure or fracture reduction involved, and b) postop management pays only about 20 percent of the allowable charge, which would not compensate for the visit RVUs.
Note that when reporting a non-operative, non-manipulative fracture care code, there must be a clear plan of action documented in the patient progress note for the initial visit, with evidence the patient has been provided follow-up care (99024).
Turn to Supply, E/M Coding for “Incomplete” Services
Occasionally, following the initial fracture treatment, a patient “defects” by virtue of an event such as a personal relocation or a switch to a new practice. In such cases, a charge correction from a fracture care code to the application (a 29xxx code) and supply codes is necessary. Coders and billers should collaborate to remediate the charge error, even if the fracture care claim has been paid.
Know Exceptions and Check Payer Rules
Physicians, coders, and billers need to understand that the CPT® codes for closed fracture treatment without manipulation represent retainer fees on behalf of the physician with regard to patient care. It’s not just the fitting to an orthotic or other medical supply that is represented by the fracture care code, but all the other work involved during the global period (with the exception of fitting to a new supply when applicable).
Patients may complain about the high cost of the closed treatment service upon receipt of an explanation of benefits because they don’t understand the retainer concept. For instance, a patient may contact the coding or billing department because $1,000 was applied to the deductible for being fitted to a wrist splint. In this case, it should be explained to the patient that the fee covers not only the splint, but also, three follow-up examinations over a 90-day period plus the cost of the splint.
With few exceptions, closed treatment without manipulation requires the provision of some sort of supply to meet the criteria for reporting a fracture treatment code. In more serious cases (such as an elderly patient falling and sustaining a hip fracture), bed rest, pain control, non-weight bearing instructions, and potentially imminent surgical preparations may be in order. Also, some fracture scenarios occur with critically ill patients where no treatment is given other than pain control for palliative care. In questionable situations, check with the patient’s payer to see what their guidelines are for reporting closed treatment for the type and location of the patient’s fracture.
Ground Rules for Fracture Care Coding
Here are some general ground rules for fracture care coding, whether operative or non-operative:
- Initial fittings of casts, splints, strappings, and other materials are included in the global service of fracture care.
- Post-procedurally, or after non-operative fracture treatment is provided, a subsequent fitting or refitting can be reported with modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period appended to the CPT® code.
- When fracture care is provided in the doctor’s office (POS 11 Office), materials may be reported separately with an appropriate HCPCS Level II code. The payer determines whether the supply will be paid.
- In a hospital setting, the facility bills for fracture stabilizing materials.
- A fracture not indicated as open (or implied by the presence of a skin wound) is considered closed.
- A fracture not indicated as nondisplaced is considered displaced.
- Additional intraoperative services may be bundled into fracture surgeries, such as debridement, bone grafts, or old hardware removal.