Break Down the Barriers to Proper Fracture Coding
CPT® code selection comes down to knowing what to look for in the note and asking the right questions.
Fractures are common but coding them isn’t always easy. Correct coding relies on you knowing how to identify both the presentation and treatment of the fracture.
To differentiate between the type of fracture and the type of treatment provided:
- Use the presentation of the fracture to select a diagnosis code.
- Use the treatment of the fracture to select a procedure code.
Case in Point
For example, a patient presents with an open tibial shaft fracture of the lower right leg. The provider opts to treat this fracture via closed treatment without manipulation, with subsequent visits for follow-up care. In this case, the correct CPT® code for the initial treatment is 27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation.
If you were to use the diagnosis presentation term “open tibial shaft fracture” for CPT® code selection, however, you would inappropriately select 27758 Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage.
Assign ICD-10-CM codes based on the presentation of the fracture. A fracture may present as either open or closed. An open fracture means that a fracture fragment has pierced the skin, exposing the fractured bone to air. Providers might use phrases like “puncture site” or “open wound down to the fracture site” to reference an open fracture. Conversely, a closed fracture does not produce an open wound at the fracture site, and the fractured bone is not exposed to air.
Assign CPT® codes based on the type of treatment. Fracture treatments include:
- Closed manipulation
- Open reduction with internal fixation (ORIF)
- Percutaneous fixation
- Closed treatment without manipulation
Closed manipulation means the provider does not surgically open the fracture site. Instead, the provider manipulates the fractured bone non-surgically to restore correct alignment.
ORIF means the provider repairs the fracture through a surgical incision, often with the use of plates, screws, or rods.
Percutaneous fixation means the provider inserts stabilizing devices, such as pins or wires, through the skin from one bone fragment to the other, usually using imaging guidance. These stabilizers are usually left in position for four to six weeks and then removed when the fracture is healed.
Closed treatment without manipulation involves the use of medical supplies to stabilize the fracture site while it heals or to support weight-bearing during the healing period. Supplies used in closed treatment without manipulation include casts, splints, slings, walking boots, braces, and crutches.
When Casting Calls for Separate Coding
All fracture care codes include the application and removal of the initial cast. When the provider treats the fracture and then places a cast, report only the CPT® code for the fracture care. The application of the cast is inherent to the fracture treatment procedure code. If, however, the provider subsequently applies or replaces the cast during a follow-up encounter, report the procedure code for casting.
Global Fracture Care vs. Itemized Billing
If you struggle with coding non-manipulative closed treatment of a fracture when casting is used, remember there are two coding methodologies to choose from:
Global Fracture Care Method
If you choose the global fracture care method, report the appropriate code for closed fracture treatment, as well as the evaluation and management (E/M) service with modifier 57 Surgical care only. Follow-up care within the 90-day global period is included in the global package. In this instance, you are not allowed to report the application of the first cast, but you may report subsequent cast applications.
If you choose the itemization method, report the application of the cast as well as the E/M service with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Report subsequent follow-up care with established patient E/M codes.
To determine which coding method to use, answer the following questions:
- Will restorative treatment be performed (surgical repair, closed or open reduction) or is it expected to be performed?
- Will the same provider perform all subsequent fracture care?
If the answers are “yes” to both questions, code the service with the global fracture care method.
If the answers are “no,” to both questions, code the service with the itemized method.
Remember to check with your payers to see what their guidelines are for reporting global fracture care.
Don’t Let Fractures Intimidate You
Coding fractures is far less intimidating when you have all the information. Always thoroughly review the provider’s documentation in the medical record and ask questions if you’re missing a piece of information necessary to correctly code.
Carol Ermis, CPC, COSC, AAPC Fellow, is the billing director at Orthopaedic Specialists of Austin, where she’s managed the revenue cycle for 13 years. She serves on the advisory board for The College of Health Care Professions and is a member of the Austin, Texas, local chapter.