Clarification:
E/M Codes With Fracture Care
Published on Sat May 01, 1999
In the February issue of PCA, we covered how to code properly when a fractured finger needs to be wrapped with a splint. The answer was to use the global fracture care codes, providing that the child is not referred to an orthopedist for the care. The article stated that the fracture care codes (the most common ones used in pediatrics are 23500, 26720, 26750, 28490, and 28510) include casting or splinting and follow-up care for 90 days, and that therefore there would be no E/M code for the visit, unless some other illness was addressed at the
same visit.
This isn't, however, strictly correct. It is possible to bill for fracture care and for an office visit at the same time, using modifier -25 on the office visit. (See the modifier -25 description in box on page 39.)
Some payers will allow it (an office visit and a fracture care code) and some wont, says Laura Neuchterlein, senior policy analyst for the American Academy of Orthopedic Surgeons (AAOS), where the AAP referred us for clarification of this issue. You cant make a blanket statement about whether you can or cant use both.
The key element, says Neuchterlein, is what kind of decision-making went into the visit. Its not likely that the child came into your exam room and announced, I have a phalangeal shaft fracture of my thumb. Would you please perform closed treatment, no manipulation, thank you very much. Rather, you as a pediatrician must decide what is wrong or what might be wrong, order the x-rays, and proceed accordingly.
As long as you are making a decision about how to handle the fracture, about what kind of treatment it requires, and how youre going to manage the care, you are going to be performing an E/M services as well, says Neuchterlein. Can you even say that a simple fracture doesnt require an E/M code? No, responds the policy analyst. It depends entirely on the situation.
Note: Surgeons would not use the modifier -25 on the office visit if they were going to proceed with surgery; rather, they would use the modifier -57, which shows that they made a decision for surgery during that visit.
Casts and Strapping Codes
Furthermore, if you are only applying a splint as an initial measure, and then sending the child for further care elsewhere, you cant use the fracture care codes. This is the best time to be using an E/M code. While its true that some plans may argue that the E/M service [...]
