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Wiki Closed Teatment Fracture Care w/o Manipulation

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volleyb13

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This is a pretty general question, I am new to this speciality, I need some help with the below scenario:

After sustaining a proximal humeral fracture, patient was seen in the hospital, x-rays taken to confirm fracture, & sling was applied in the hospital.

Patient now being seen in the office, Doctor re-examines the patient, states will treat fracture conservatively, and patient should continue in her sling, no manipulation is performed. Patient will follow up with office in 10 days for repeat x-rays to check for any displacement of her fracture.

My question is, can the doctor bill for closed treatment of proximal humeral fracture; without manipulation if he did not actually apply the sling & only agreed with the plan of care done in the hospital?

Any info/help that could be provided would be great!! Thanks so much!! :rolleyes:
 
The ER doctor should be billing for an ED visit and a splint application so your doctor has the choice of how he wants to bill. He can either bill "Global” reporting of the services by using the 90-day, global fracture code or “Itemized” reporting of the services by reporting each patient encounter separately. The physician reports each service independently and does not enter into a 90-day global period. Hope that is helpful to you.
 
That makes sence, just was not sure if the doctor in the office did not actually apply the sling, that it would still be okay to bill the 23600. Thank you very much for your reply. :)
 
A decade later, how do you feel about this answer now? If you're still in orthopedics, do you still feel your physician can bill 23600 with no additional treatment? How about if they did not even put the sling back on and stated to use as needed? If so, would you also bill the OV+57?
 
Billingandcoding2 said:
A decade later, how do you feel about this answer now? If you're still in orthopedics, do you still feel your physician can bill 23600 with no additional treatment? How about if they did not even put the sling back on and stated to use as needed? If so, would you also bill the OV+57?
Click to expand...
I know that you are asking the previous poster what their position is on billing the 23600 without actually providing additional treatment after 10 years (probably because of the major coding changes in the last decade) but I am going to weigh in on this question.

Working for a commercial insurance company if the medical record doesn't support that the ortho specialist did anything to actually treat the fracture, i.e., they didn't apply the sling after examining the patient, we would not cover the global billing of 23600 since they did not perform the initial procedure for treatment of the fracture as this was done by the ED provider. If there was ongoing post-op care provided by the ortho specialist that meets the criteria for billing 23600, we might cover the post-op portion of 23600 if the provider billed modifier 55 with 23600 and the documentation supports that the provider provided treatment for the full post-op period.

However, that is going to require that the provider saw the patient more than just this one visit listed by the OP. If the provider only saw the patient for this fracture one time, then they would likely be able to bill an E&M procedure. However, modifier 57-Decision for Surgery would not be appropriate since the surgery, 23600, was already performed by the ED physician and there was no surgery considered by the ortho specialist in the OPs original post.
 
Resurrecting an old post! LoL

Would also add, there has been so much discussion about fracture care and this topic. I would also suggest searching the forums for more recent discussions on this, there are so many with good info. :)
 
amyjph said:
Resurrecting an old post! LoL

Would also add, there has been so much discussion about fracture care and this topic. I would also suggest searching the forums for more recent discussions on this, there are so many with good info. :)
Click to expand...
I'm having a hard time finding them.....coming back to search again for a provider that wants supporting information on this topic. Still can't find recent posts.
 
Billingandcoding2 said:
I'm having a hard time finding them.....coming back to search again for a provider that wants supporting information on this topic. Still can't find recent posts.
Click to expand...
This original was 14 year ago and the recent activity was 3.

What is the provider looking for specifically?

Depending on the health plan being billed and MAC:
CMS NCCI Manual resource: https://www.cms.gov/files/document/04-chapter4-ncci-medicare-policy-manual-2026-final.pdf
Noridian Article: https://www.cms.gov/medicare-covera...keywordtype=starts&keyword=fracture care&bc=0
Consult the CPT Book at the beginning of the surgery/musculoskeletal system section. Each anatomical section may have further closed tx direction or info depending on the code.
Check health plan specific policies, also look up any casting/splinting/strapping policy as well.

These are a little more recent AAPC threads:
I

Wiki Thread 'Fracture Care Help'

Hi,

I am wondering if anyone is willing to help me with fracture care. I am specifically looking for help on how to bill if patient was seen in ED then told to follow up with ortho. I bill for the ortho. Thanks,
J

Wiki Thread '25600 documentation requirements'

I'm in a disagreement with another coder on if this documentation meets the requirements. Our provider has stated that the patient had distal radial fracture and instructed the patient to continue brace w/ non weightbearing. Which they say is supportive of billing the 25600. When I read the CPT description this provided info doesn't seem like enough to support the billing, but I'm unable to find supporting material.
A

Wiki Thread 'fracture care'

Where can I go to get basis for charging fracture care? Does charging for fracture care require bracing/cast/DME fitting? Can I charge fracture care when my provider states, "continue shoulder sling applied in ER, see patient in our office in 2 weeks". Where can I go to get answers/guidelines?
S

Wiki Thread 'Closed Fracture Care in the Inpatient Setting'

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...
K

Wiki Thread 'Fracture Care'

Am I the only one who gets a bit confused when to code the fracture care using modifier 25 or 57.

If a patient is seen in our urgent care and they have a fracture and sling applied only, follow up with our internal orthopedic. We only code E/M
Patient follows up with ortho, fracture with no manipulation, splint applied. We code E/M and fracture care code but when are you to use modifier 25 or 57 with fracture care code?

Majority of fracture care codes with or without manipulation are 90 day global.

Any source or help is appreciated. Thank you

ACEP resource: https://www.acep.org/administration...hopedic-fracture--dislocation-management-faq/
NAMAS: https://www.doctorsmanagement.com/blog/understanding-office-based-fracture-care/

AAOS NOW Archives have a # of articles on fracture care (if your provider is a member or you can get into it): https://www.aaos.org/quality/coding-and-reimbursement/aaos_now_article_archives/

KZA: $, but exactly what you may need: https://educate.kzanow.com/products/fracture-care-step-by-step-2

KZA Article, old but still true: https://www.kzanow.com/coding-coach...nt-of-finger-fractures-one-code-or-four-codes
 
amyjph said:
This original was 14 year ago and the recent activity was 3.

What is the provider looking for specifically?

Depending on the health plan being billed and MAC:
CMS NCCI Manual resource: https://www.cms.gov/files/document/04-chapter4-ncci-medicare-policy-manual-2026-final.pdf
Noridian Article: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53322&ver=16&keywordtype=starts&keyword=fracture care&bc=0
Consult the CPT Book at the beginning of the surgery/musculoskeletal system section. Each anatomical section may have further closed tx direction or info depending on the code.
Check health plan specific policies, also look up any casting/splinting/strapping policy as well.

These are a little more recent AAPC threads:
I

Wiki Thread 'Fracture Care Help'

Hi,

I am wondering if anyone is willing to help me with fracture care. I am specifically looking for help on how to bill if patient was seen in ED then told to follow up with ortho. I bill for the ortho. Thanks,
J

Wiki Thread '25600 documentation requirements'

I'm in a disagreement with another coder on if this documentation meets the requirements. Our provider has stated that the patient had distal radial fracture and instructed the patient to continue brace w/ non weightbearing. Which they say is supportive of billing the 25600. When I read the CPT description this provided info doesn't seem like enough to support the billing, but I'm unable to find supporting material.
A

Wiki Thread 'fracture care'

Where can I go to get basis for charging fracture care? Does charging for fracture care require bracing/cast/DME fitting? Can I charge fracture care when my provider states, "continue shoulder sling applied in ER, see patient in our office in 2 weeks". Where can I go to get answers/guidelines?
S

Wiki Thread 'Closed Fracture Care in the Inpatient Setting'

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...
K

Wiki Thread 'Fracture Care'

Am I the only one who gets a bit confused when to code the fracture care using modifier 25 or 57.

If a patient is seen in our urgent care and they have a fracture and sling applied only, follow up with our internal orthopedic. We only code E/M
Patient follows up with ortho, fracture with no manipulation, splint applied. We code E/M and fracture care code but when are you to use modifier 25 or 57 with fracture care code?

Majority of fracture care codes with or without manipulation are 90 day global.

Any source or help is appreciated. Thank you

ACEP resource: https://www.acep.org/administration...hopedic-fracture--dislocation-management-faq/
NAMAS: https://www.doctorsmanagement.com/blog/understanding-office-based-fracture-care/

AAOS NOW Archives have a # of articles on fracture care (if your provider is a member or you can get into it): https://www.aaos.org/quality/coding-and-reimbursement/aaos_now_article_archives/

KZA: $, but exactly what you may need: https://educate.kzanow.com/products/fracture-care-step-by-step-2

KZA Article, old but still true: https://www.kzanow.com/coding-coach...nt-of-finger-fractures-one-code-or-four-codes
Click to expand...
I appreciate your effort - I still am not seeing reputable references on what exactly qualifies as "closed treatment without manipulation" - we see a good amount of proximal humerus fractures; patient arrives in sling and no further strapping is done, we are diagnosing and taking on the care through healing. My providers want written proof of exactly when you can/cannot bill the fracture care. I have been unable to locate this over several years of research so we default to itemized billing in these instances. Same for fractures that do not require stabilization, such as clavicle.

I'll see if they can access the articles on AAOS. Thank you!
 
The definition of fracture care was changed in CPT over two years ago and no longer requires definitive treatment to be performed.
Since that redefinition happened, ER docs began rampantly coding fracture care in the ER when all they did was throw a splint or sling on, with the use of a -54 modifier.
This would generally lead the orthopaedist following up to use the fracture code with a -55 modifier.
This may lead to fracture care codes becoming zero-day globals, eliminating the issue.

In MOST settings, if your orthopaedist actually follows the patient, you will make more through itemized billing, especially given that the wRVU value of the office visits went up by 20-30% in 2021 and the office visits included in the fracture care global were never revalued.
 
The CPT book, CMS, and your MAC are the reputable resources. Policy of the health plan being billed comes next because they may have their own "rules". AAOS and KZA third for info. In your example, the provider can choose whether they want to bill the global fracture care or the itemized route. I would go with you and tell them to do itemized. It negates the 54/55 issue as well. Then you aren't also dealing with global and, if patient should come in for something else in the same office, 24 or other mods. In some orthopedic practices, I have seen where they choose not to use any of the closed without manipulation and only code global if they actually reduced it. I had providers that never wanted to use the global in office at all, and providers that always wanted to. (LoL) Look in the CPT book at the beginning of the musculoskeletal section under "Closed treatment" and "Reporting Fracture and/or Dislocation Treatment". That is their "written proof" of it. Then, some specific codes have parentheticals and direction of when you can or can't use it and/or direct you to go to the E/M.

Agree with Dr. Raizman; when I worked at an orthopedic practice, a study was done where it showed it was generally more advantageous to go the itemized route. I think MGMA had info on it, might be a bit old now.
For example, in the MCR PFS 23600 has 2.93 Work RVUs and, depending on the location, anywhere from $335-$498 non-facility. Let's say you had a 99204 on the 1st office visit instead, that's 2.60 Work RVUs and $162-$222. Depending on the # of follow up office visits, if a couple 3's, that would put you over the global amount, 99213 has 1.30 Work RVUs. Depending on how many f/u they have and if it's routine healing w/ no complications, etc. etc.

This is also another area of info on 54/55: https://www.wpsgha.com/guides-resources/view/88
54/55 and global surgical package info in here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

My blurb whenever talking about fracture care from the patient billing side and patient satisfaction side of things: Does the practice have a procedure to explain to patients/guarantors that this means they will be in a global "surgical" period. Because, when they get the EOB, and that big charge that many times has the words "surgery" on it, they are going to call and tell you no one had surgery. And be upset because it was not explained up front. Not saying the non-op fx code should not be used, I am just pointing out the repercussions of it. I have spent countless hours explaining non-operative fracture care to patients and taking angry phone calls when they did not get that information up front.

Then you have some random different info from specific health plans where they don't want the global fracture care codes unless manipulation is done which they call "restorative" in this example: https://providers.highmark.com/cont...imbursement-resources/hct-article-feb2019.pdf
 
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