Part B Insider (Multispecialty) Coding Alert

Published on Wed Jan 12, 2005 PDF

Can you explain your doctor's fracture care  decisions to auditors?

Flexibility is good, but not when it comes to fracture care, experts say.

CPT gives you two different choices when billing for fracture care. You can bill for a global fracture care code, which includes cast application, an evaluation and management visit, and all follow-up visits for 90 days. Or you can bill on an itemized basis for everything relating to cast application.

The reimbursement usually works out to be roughly the same for global fracture care codes as for itemized billing, coding experts say. (See PBI, Vol. 5, No. 15.) But some doctors may want to select one option or the other, depending on how many follow-up visits they think the patient will need. The more follow-ups, the more profitable the itemized approach will be.

Instead of deciding on an approach for each patient separately, "you should pick a stance and go with it," says Michelle Logsdon, a consultant with Cash Flow Solutions in Cherry Hill, NJ. That way, if an auditor wants to know why you billed itemized or global for a particular patient, you can explain that the doctor always bills that way.

Don't Look Suspicious

If your physicians use both fracture billing techniques, auditors will "think you pick and choose for your benefit, not the patient's," says Mary Brown, coder with OrthoWest in Omaha, NE. "They never give you the benefit of the doubt."

One rule of thumb: The American Medical Association's CPT guidelines and various CPT Assistant articles clearly state that "if one is going to take on the patient, treat their fracture and follow them through the healing phase, one should certainly report the global fracture code," says consultant Heidi Stout coding and reimbursement manager at UMDNJ-RWJ University Orthopedic Group in New Brunswick, NJ. "That's the reason those codes were created." But she also notes the American Academy of Orthopedic Surgeons has put out some guidance giving surgeons more leeway.

One exception to the rule: Your practice could have a policy that states you'll report global codes for all fracture care except for non-manipulation fractures, notes Logsdon. Therefore, you would report non-manipulation fracture care with the itemized approach. "Doctors sometimes feel inappropriate billing for fracture care when the facture is non-manipulated," because they can receive a large lump sum for less work, she explains. But with E/M reimbursement so low, billing the global fracture care code makes sense because the physician did perform medical decision-making to treat the non-manipulation fracture and deserves adequate payment for his services, Logsdon contends.

Worst possible thing: At all costs, don't divide your billing techniques by carrier and bill all Medicare patients on an itemized basis and all worker's comp or no-fault insurance for global fracture care, Logsdon warns. You could get into serious trouble if you're not applying the same billing rules consistently, especially if your decision seems profit-driven.