Orthopedic Coding Alert

The patient's history should reveal whether the patient was initially seen in the emergency department or another physician's office and later sent to your orthopedic practice for further care of the fracture. If the date of injury is greater than two weeks ago, you should confer with the orthopedic surgeon regarding the billing of fracture care. Some fractures heal quickly, and if the fracture is healed or mostly healed, fracture care would not be appropriate.

When You Shouldn't Bill Global Fracture Care

The fracture care codes would not be appropriate if the following criteria apply:

1. The fracture is old
2. There is a nonunion of the fracture
3. The fracture is healed or mostly healed
4. Your doctor is NOT going to care for this fracture for the next 90 days
5. No follow-up visits are recommended
6. Patient is scheduled for a more extensive procedure like percutaneous pinning or open treatment with or without fixation.

In the above cases, you would bill the appropriate E/M service with applicable casting codes instead of a global fracture care code. If criteria number 6 applies to your patient and you plan to perform the surgery the same date as the E/M visit (or the following day), you should append modifier 57 (Decision for surgery) to the E/M code so the insurer pays it and doesn't bundle it into the surgery code.

If you simply bill casting and an E/M code (along with the casting supply HCPCS code[s]), some carriers require you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Select Your Fracture Care Code

CPT codes that describe a "closed treatment of a fracture without manipulation" or "closed treatment of a fracture with manipulation" are the codes most commonly billed in the orthopedic office setting.  
  
You may wonder whether your bottom line will be affected when you choose fracture care rather than an E/M with casting. Check out the reimbursement examples at the bottom of this page. The examples use Medicare payment amounts in a practice area of Nebraska for a fractured distal radius treated without manipulation.

As you can see, billing fracture care nets you only about one dollar more than billing "unbundled," assuming you report 99202 for the new patient office visit, as the surgeon in our example did. This example uses Medicare's reimbursement rates, but some major insurance companies may pay at a higher or lower rate than Medicare. One ad-vantage to fracture care billing is that you get your "office charges" paid with the initial visit and you don't have to wait to receive your reimbursement with each office visit. 

Do your homework. Pick the most common fracture care codes that your practice reports. Determine which fractures usually require casting at the initial visit, and find the average number of follow-up visits for each code. Use the reimbursement amounts for each of your major insurance carriers in an equation like the example above. This will help you determine which method of billing is best for your practice. This should be checked annually because your contracts and/or the RVUs may change.

Tip: You should also check with your major carriers to see whether they require global fracture care billing when a fracture diagnosis is present.

After you have done your research and determine your office policy, coding fractures can be a breeze as long as you are consistent.

Mary Brown, CPC, CMA, is the orthopedic coding specialist at OrthoWest PC, a nine-physician practice in Omaha, Neb.