Orthopedic Coding Alert

In the following situations, how should we be coding for our physicians fracture care:

Judi Oakley, Manager, Billing and Collections
Orthopedic Associates of Central Maryland, Baltimore

Question 1: Fracture patient who was seen in the emergency department by the ED physician is diagnosed and casted, and then sent to our practice for follow-up care.

Answer 1: You have two options, depending on which best fits your situation:

A.) The orthopedist should use the appropriate fracture care code and append the -55 modifier (post-op management only). The ED or family physician should bill for the fracture code and append modifier -54 (surgical care only). However, to use this option, youll want to establish a verbal agreement with your local ED. If both your practice and the ED or family physician dont coordinate the use of modifiers -54 and -55, one of you wont get paid.

The payer, who gets two bills with the fracture code for the same patient, would pay the first claim received and deny the second. You can appeal this decision; however, you can avoid delays by communicating with the ED physician ahead of time, notes Susan Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC.

B.) Itemized billing may be a better option to circumvent denials. For example, the ED physician bills his portion of the fracture code with modifier -54.

The orthopedist would then bill an itemized treatment of fracture follow-up, including all office visits, cast application, as well as x-rays. Supplies such as over-the-counter braces and cast supplies are not included in fracture care, although fiberglass supplies may be payable.

Note: The CPT states that fracture care includes the initial application and removal of that same cast when removed by the same physician or member of a group who billed the application. Subsequent replacement of cast and/or traction device is billable separately.

Some carriers will still limit the total amount paid to the orthopedist for E/M services to the equivalent of the portion of the fracture care fee designated as post-op about 21 percent of the total fee, Stradley says.

Question 2: Fracture patient is seen by a member of our group who is on call in the ED, then another physician in our group provides follow-up care.

Answer 2: Our sources tell us that, for payer purposes, it doesnt matter which physician in your practice bills for follow-up care, because they are under the same billing number. After reimbursement is received from the payer, disbursement then becomes a matter of internal adjustment between the orthopedist who provided the initial care and the one who provided follow-up. Every practice may be different. For example, one practice told us they allocate 79 percent to the physician who provided the initial care; the remaining 21 percent of the fracture care reimbursement to the physician who provided follow-up care. (The second physician does not charge for any visits within the 90-day global package.) In this case, the allocation figures were derived from the pre-op/intra-op and post-op figures published in Medicodes Billing and Compliance Handbook. Most fracture care codes, the book says, have a 21 percent post-op allocation.

Note: If this were a workers comp case, check its global fee period and you may find you can bill follow-up care codes sooner than Medicares 90 days. For example, in Michigan, workers comp only bundles 14 days into a fracture care code, so orthopedists are allowed to bill on the 15th day.