Wiki Closed Fracture Care in the Inpatient Setting

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sparkles1077

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How is your orthopedic group coding for closed fracture care in the inpatient setting? Are you coding the closed fracture care at the initial consult when it is probable or assumed? What do you do when a second orthopedic surgeon in your group sees the patient later in the stay and recommends the follow up care (and orders)? Would you bill the closed fracture care at the initial consult only?

Just wondering because our orthopedic surgeons want to bill for closed fracture care in the inpatient setting which is fine, but it becomes complex when they aren't certain at the initial visit whether the patient will have surgery or resume closed fracture care. I guess we could assume and then add modifier 58. However, there are also encounters where it is assumed and the hospitalist recommends a follow up at discharge, but the patient never follows up.

In the past, I have seen the itemized billing method for the inpatient setting, but it sounds like our physicians want to bill closed fracture procedure codes instead.
 
So assuming these are all Closed Tx Without Manipulation, correct?

Whoever sees the patient first codes the fracture care code. If another practitioner in the same group sees the patient subsequently, then you would do a -54 modifier initially and then everyone else gets the -55 modifier.

If there's a question as to whether the patient needs surgery or not, it would be pretty inappropriate to use a fracture care code, because that implied DEFINITIVE management of the fracture, not temporizing care.
 
NRaizman said:
So assuming these are all Closed Tx Without Manipulation, correct?

Whoever sees the patient first codes the fracture care code. If another practitioner in the same group sees the patient subsequently, then you would do a -54 modifier initially and then everyone else gets the -55 modifier.

If there's a question as to whether the patient needs surgery or not, it would be pretty inappropriate to use a fracture care code, because that implied DEFINITIVE management of the fracture, not temporizing care.
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Thank you Dr. Raizman.

Yes, the situation is for closed treatment without manipulation. Interesting, we typically use the 54 and 55 modifiers when there is a transfer of care as in the CMS guidelines. For example, ER doctor provides non-manipulative fracture care and then patient follows up with orthopedics. Do you know of a reference that supports using the modifiers 54 and 55 in the same group practice? Appending is also difficult at the time of coding when the coder does not know that another surgeon will follow up during the same admission a month later (Ortho Trauma).

Unfortunately, our surgeons are using the non-operative fracture care codes in the probable situation also - when they are not certain about the surgery, they are assuming non-operative fracture care and coding for this procedure. If the patient does end up having surgery, modifier 58 is appended.
 
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CMS' Claims Processing Manual doesn't specify whether the physicians are in the same group practice for -54 or -55. It does, however, specify that, if physicians are in the same group practice, you only bill one global. So, if the second doc wants to get paid, he or she needs to do -54/-55. It would be entirely up to your practice to split the reimbursement appropriately after-the-fact and not rely on claims processing at all. That may actually be preferable. There is no financial advantage to using the -54 and -55 modifiers.


From CMS: (Ch 12, Section 40.2):

2. Physicians in Group Practice When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is shown as the performing physician. (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the group billed for the surgical care and the postoperative care as separate line items with the appropriate modifiers.)

3. Physicians Who Furnish Part of a Global Surgical Package Where physicians agree on the transfer of care during the global period, the following modifiers are used: • “-54” for surgical care only; or • “-55” for postoperative management only. Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier. Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
 
When I managed a large ortho group that took trauma call, if it was not definitive/restorative and only temporary stabilization, the closed fracture codes w/ or w/o manipulation weren't coded. This was in a big vacation/tourist area so we had a lot of patients who did not live locally and the 54/55 would come into play for external providers. I think it depends on your group and what they want to do. I agree with Dr. Raizman; it can be done in the background via accounting and not at the claims level.
Our providers had an understanding and we had an internal policy for it. I think it depends on your group. Trying to manage 54/55 internally can be a nightmare. Trying to do it correctly for external providers is enough of a problem. The providers I worked with had an understanding that sometimes a patient might be in a global from the ED or IP and they were helping a partner out with post op care. This place also had dedicated trauma coders that followed the providers and patients through the whole episode of care though so they knew what was going on. We also had a slight delay on trauma coding so we would know better what happened during the whole case. You might have someone IP for weeks and have to split out all the different care/surgery/rounds if it was a big trauma case. The basic ED or observation quickies are easier.

It really depends on the scenario. Is the patient only being seen in the ED and may not f/u with your group? Is the patient admitted and your group is following them throughout the episode? Do they have multiple fractures/injuries. For example, you might have a closed treatment w/ manipulation of a fracture which was definitive/final but they also have fractures in other areas requiring ORIF. So you will have lots of 24/25/58/78/79 possibly coming into play.

It sounds like your group needs to have a discussion about the route they want to take with this. You would probably need input from the rev cycle management and CFO/accounting too depending on the result if there is no procedure or policy for it currently.
 
I wholeheartedly agree with Amy here.

If this is a significant reimbursement driver, it might make sense to do a mockup of different scenarios for reimbursement and bring all your heads together to find the ideal pathway that represents coding ease and maximizing reimbursement. The "definitive/restorative" definition for fracture care was revised by CPT two years ago, and you should pay attention to that specifically in the CPT book to help guide you. Specifically, casting/splinting for comfort or to temporarily stabilize the fracture does NOT qualify as Closed Treatment.

For the record, historically the closed fracture treatment codes were put forward (by the great Brad Henley and a few others) because orthopaedic traumatologists would have to take care of multiply injured patients and everything but the single operative fracture would get kicked out. These codes were then misused by ER docs for years when it was clear that they would not be providing definitive management. The recent change in definitions allowed ER docs to use the codes more easily, but with a 54 modifier - it's still mostly garbage and a money-grab, mostly by Urgent Care facilities, as the ER/UC is rarely providing definitive or restorative management or providing the appropriate guidance, and they're rarely even putting on the definitive splint, but they got the changes passed through CPT. As someone who provides definitive fracture management, this makes me bristle, but it's the law of the land now...
 
Thank you Amy and Dr. Raizmin for the feedback. My understanding is that CMS defines transfer of care as between different group practices/hospitals so modifiers 54 and 55 would not apply within the same group practice. Physicians of the same specialty and practice are also considered the same provider.

From AAOS: "In 2025, the Centers for Medicare & Medicaid Services (CMS) expanded its documentation requirements when a provider performs a surgical procedure with a 90-day global surgical package but transfers postoperative care to another provider outside of their group practice. This change was made to enhance continuity of patient care through better communication between providers, standardize documentation with clear protocols for transfer-of-care coordination, reduce errors in postsurgical care, increase transparency regarding reimbursement in line with value-based models of care, and reduce overpayments or duplicate billing. Medicare expanded its guidance to say that postoperative care can be transferred to a provider of the same specialty but not within the same group practice’s taxpayer identification number."

I will definitely ask about any internal policy - I have just been told it is up to the physician, but I am not certain if the physicians have agreed that the first physician can take the non-operative global fracture care code during while other physicians in the same group practice follow the patient.

I am just confused when the physician is initially uncertain about surgery vs closed fracture treatment, and then later in the inpatient stay or after inpatient rehab in the same facility another physician of the same practice documents the plan and follow up for closed fracture treatment along with an order. I was thinking they could bill E/Ms until the decision for closed fracture treatment, however, I can see this may conflict with the global surgery rules - "When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount)" (Chapter 12 section 40.d)

I agree the definitive/restorative terms were omitted in 2022 - I do not see these terms in the 2025 CPT book.

We considered the presentation of a fracture as possibly qualifying for closed treatment by itself, and then if a surgery took place later a modifier 58 would be appended. I agree with the feedback above that this would not qualify as closed treatment. Everything I find points to a requirement to follow the fracture to healing.

I empathize with the frustration with ER and Urgent Care. I used to audit those groups and our team tried to explain they could not take the entire global for fracture care, but they just adjusted their documentation to state follow up to get the fracture care past us - but they never followed up!!
 
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If it is uncertain at the start of care, you probably should not bill the global fracture care. Just do the E/M route (i.e.; itemized). However, once it is decided to bill itemized, you shouldn't switch to the global later after billing E/Ms and possibly the casting and supplies or splinting (if done). This way, if they are not in a global for that fracture, anyone following up later whether in office or still admitted is getting the E/M. Another idea, if your group PAs or NPs saw a patient in the ED only, they would not bill global even if manipulated so that any f/u provider in office would get E/M later. A physician might decide at the first in-office visit to go global at that time which is ok (imo). This is really scenario driven though. I could see where a patient with multiple fractures might be seen first for one E/M by the on-call with no decision made and then maybe the next day the subspecialist of the same group decides on non-op. It might be ok in a case like that where they were waiting for the hand/wrist guy or F&A, etc. I don't think there is a black and white answer to it.

I had one provider I used to go round and round with all the time. He would see a patient in office for a nondisplaced fracture, start out billing E/M a couple times and then later decide he wanted to switch to the global. I would not allow it since he had already picked the itemized route. This was all in office though. Think of it from the patient perspective too. They pay a couple co-pays have office visits on their EOB and then suddenly they see a bigger global charge for the same "problem". It causes much grief to the customer service and rev cycle people trying to explain. Trying to explain non-op fracture care to patients is an art. The poor folks are freaked out when they see a "surgery" on their EOB because the closed codes live in the surgery section of CPT. If this process is not explained up front, you have major headaches on the back end. Ask your rev cycle team and anyone that takes patient billing calls. :)

When talking ED, Observation or IP things get muddled. What you say here is a key, " Everything I find points to a requirement to follow the fracture to healing." If the provider billing the global fracture care does not intend to follow it through, they should append the correct modifier or not bill it at all and go E/M.

Novitas has an ok explanation, it is from 2021 though.
The newer CMS global book explains well: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

I am not advocating to never bill global however, it needs to be done correctly. By billing the global without a modifier, the provider is taking credit for the full RVUs (pre, intra & post service work). The exception is the few 0 day globals.

Yes, I thought it was that you can't 54/55 within the same group if the providers assign the $ to the group.
 
amyjph said:
If it is uncertain at the start of care, you probably should not bill the global fracture care. Just do the E/M route (i.e.; itemized). However, once it is decided to bill itemized, you shouldn't switch to the global later after billing E/Ms and possibly the casting and supplies or splinting (if done). This way, if they are not in a global for that fracture, anyone following up later whether in office or still admitted is getting the E/M. Another idea, if your group PAs or NPs saw a patient in the ED only, they would not bill global even if manipulated so that any f/u provider in office would get E/M later. A physician might decide at the first in-office visit to go global at that time which is ok (imo). This is really scenario driven though. I could see where a patient with multiple fractures might be seen first for one E/M by the on-call with no decision made and then maybe the next day the subspecialist of the same group decides on non-op. It might be ok in a case like that where they were waiting for the hand/wrist guy or F&A, etc. I don't think there is a black and white answer to it.

I had one provider I used to go round and round with all the time. He would see a patient in office for a nondisplaced fracture, start out billing E/M a couple times and then later decide he wanted to switch to the global. I would not allow it since he had already picked the itemized route. This was all in office though. Think of it from the patient perspective too. They pay a couple co-pays have office visits on their EOB and then suddenly they see a bigger global charge for the same "problem". It causes much grief to the customer service and rev cycle people trying to explain. Trying to explain non-op fracture care to patients is an art. The poor folks are freaked out when they see a "surgery" on their EOB because the closed codes live in the surgery section of CPT. If this process is not explained up front, you have major headaches on the back end. Ask your rev cycle team and anyone that takes patient billing calls. :)

When talking ED, Observation or IP things get muddled. What you say here is a key, " Everything I find points to a requirement to follow the fracture to healing." If the provider billing the global fracture care does not intend to follow it through, they should append the correct modifier or not bill it at all and go E/M.

Novitas has an ok explanation, it is from 2021 though.
The newer CMS global book explains well: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

I am not advocating to never bill global however, it needs to be done correctly. By billing the global without a modifier, the provider is taking credit for the full RVUs (pre, intra & post service work). The exception is the few 0 day globals.

Yes, I thought it was that you can't 54/55 within the same group if the providers assign the $ to the group.
Click to expand...
Thank you Amy! I agree the itemized billing method is optimal for the inpatient context I described (Physician 1 consults and is uncertain of closed vs surgery; Physician 2 later in the inpatient stay confirms closed with f/u plans and also follows the patient in the outpatient setting). I initially recommended itemized, unfortunately, our physicians want to bill the closed fracture care regardless of context/scenario. It works well in the outpatient setting - the physicians bill for closed fracture care and the APPs provide follow up. I agree they would need to start with closed fracture care at the beginning and should not change billing methods in the outpatient setting.

The inpatient setting seems gray. If the physician has not decided on non-operative versus surgery, then definitive fracture care has not started? Or is the fact that the physician is following in the inpatient setting and has not signed off enough to consider definitive fracture care? I wouldn't see the situation you described in the ED(Our MDs always do the consults) - APPs bill E/M in the ED and then physicians could follow with global, but it seems similar. The E/M is billed when uncertain, and then a physician follows with global. I am not able to find a black and white answer to these questions.

For inpatient there wouldn't be copays for each day. Perhaps there would be two deductibles though, one for inpatient and one for the surgery, so if itemized was selected for inpatient there would be one deductible and then copays for the outpatient follow up visits.

I appreciate all the feedback from this forum!!!
 
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