Wiki Fracture Care Coding - ED to Ortho

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dmjbear

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When a patient is treated in the emergency room for a fracture (with or without manipulation), do we code an EM level or the fracture CPT with modifier 54? What type of documentation is required indicating transfer of care to an ortho provider? Does the ED provider just need to state follow up with your ortho provider and the ortho provider then bills with the same fx CPT mod 55? What constitutes documentation of transfer of care?

Should ED be considered in the rule for fracture care coding, as they only see the patient for a short time (in that one visit) and the ortho provider will follow for the 90 days?

Please provide resource information and links with regard to your response. Thank you -
 
Here are some references:
This has specific scenarios. It also depends on internal policy. Some say only code the fracture care if manipulation was performed. So, if the patient is put in a cast or splinted but no manipulation they would say to code the E/M and supplies/casting.


There is some related but not specific to your question info here: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-4.pdf
G. Fractures, Dislocations, and Casting/Splinting/Strapping
 
We have a foot and ankle surgeon that is insisting that he can bill the global fracture code for non manipulative fracture care when no dme is provided. Many times the patient comes to us already in a boot. We gave him the info attached. Are we wrong?
 

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  • Fracture guidelines.pdf
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kpichon@dsmcapitalortho.com said:
We have a foot and ankle surgeon that is insisting that he can bill the global fracture code for non manipulative fracture care when no dme is provided. Many times the patient comes to us already in a boot. We gave him the info attached. Are we wrong?
Click to expand...
Can you copy paste the PDF you have above so no download is required please?

In my opinion, the provider doesn't have to provide the DME to code the closed fracture code. For example, if the patient went to urgent care for a medial mall. fracture and was told to f/u with ortho and they gave the patient a boot (and did not bill fracture care, or billed it with a 54 mod). The ortho provider can bill closed treatment w/o manipulation (27760) and (document that they) put them back in the same boot. Why would they bill another boot or give a new one when the patient already had one? If it was the appropriate boot. As long as they are going to provide the global care of the fracture. It would require a 55 mod if the urgent care billed w/ 54. They can also choose to go the E/M route and not put them in a global.

More info:

This has always been a huge debate. It's convoluted to understand. I would have disagreements with one of my foot and ankle guys. He had already seen the patient for one E/M and had them come back in a week-ish later to check and see if the fracture was going to require surgery. If they could be managed with closed treatment he would want to bill the closed CPT at the second visit. I had to explain it was not fair to start the patient out with an E/M and then put them in a global at the second visit. You have to pick one or the other from the get-go either E/M or global. The patients don't understand how it works. In my experience they were almost always unhappy because unfortunately, the clinical providers and admin staff of the clinics don't always do a good job of explaining global fracture care. It would look like a "surgery" on their EOB, big a bigger fee, and sometimes go 100% to their deductible. Where, with the E/M they would have had a smaller amount due per visit (possibly). Then, the revenue cycle staff are left to try and do service recovery and explain why they see a "surgery" on their EOB, even though it was not an open surgery. And, they are ticked off about the big dollars. A lot of times the full global is not met and they don't come back but maybe 1 time.
 
amyjph said:
Can you copy paste the PDF you have above so no download is required please?

In my opinion, the provider doesn't have to provide the DME to code the closed fracture code. For example, if the patient went to urgent care for a medial mall. fracture and was told to f/u with ortho and they gave the patient a boot (and did not bill fracture care, or billed it with a 54 mod). The ortho provider can bill closed treatment w/o manipulation (27760) and (document that they) put them back in the same boot. Why would they bill another boot or give a new one when the patient already had one? If it was the appropriate boot. As long as they are going to provide the global care of the fracture. It would require a 55 mod if the urgent care billed w/ 54. They can also choose to go the E/M route and not put them in a global.

More info:

This has always been a huge debate. It's convoluted to understand. I would have disagreements with one of my foot and ankle guys. He had already seen the patient for one E/M and had them come back in a week-ish later to check and see if the fracture was going to require surgery. If they could be managed with closed treatment he would want to bill the closed CPT at the second visit. I had to explain it was not fair to start the patient out with an E/M and then put them in a global at the second visit. You have to pick one or the other from the get-go either E/M or global. The patients don't understand how it works. In my experience they were almost always unhappy because unfortunately, the clinical providers and admin staff of the clinics don't always do a good job of explaining global fracture care. It would look like a "surgery" on their EOB, big a bigger fee, and sometimes go 100% to their deductible. Where, with the E/M they would have had a smaller amount due per visit (possibly). Then, the revenue cycle staff are left to try and do service recovery and explain why they see a "surgery" on their EOB, even though it was not an open surgery. And, they are ticked off about the big dollars. A lot of times the full global is not met and they don't come back but maybe 1 time.
Click to expand...
you should be able to download the pdf but, if you are having trouble you may need to speak to your IT rep enable cookies on this website. Here is the link to the same info. https://www.aapc.com/blog/41562-dont-break-your-fracture-care-revenue-cycle/
 
kpichon@dsmcapitalortho.com said:
you should be able to download the pdf but, if you are having trouble you may need to speak to your IT rep enable cookies on this website. Here is the link to the same info. https://www.aapc.com/blog/41562-dont-break-your-fracture-care-revenue-cycle/
Click to expand...
No, I don't download unknown PDFs and attachments from the web is why. Thanks for the link, I have seen that one.

I agree with the surgeon in your example. Even if the provider office did not bill for the DME (boot). If they already came in with one and it was reapplied in my opinion the provider can choose billing non-op fracture care global in that instance.

I disagree with the information in that link that it always requires a medical supply. There are no citations or sources for where that information is coming from or what backs that statement up in the article. It also says this after that first part: "With few exceptions, closed treatment without manipulation requires the provision of some sort of supply to meet the criteria for reporting a fracture treatment code. In more serious cases (such as an elderly patient falling and sustaining a hip fracture), bed rest, pain control, non-weight bearing instructions, and potentially imminent surgical preparations may be in order. Also, some fracture scenarios occur with critically ill patients where no treatment is given other than pain control for palliative care. In questionable situations, check with the patient’s payer to see what their guidelines are for reporting closed treatment for the type and location of the patient’s fracture."

I personally never use AAPC articles or references to try & back up what I advise my providers. It has to be CPT, AMA, NCCI, CMS, HCPCS, CPT Asst., AHA Coding Clinic, state regs, payer specific rule, AAOS, etc. While it is most common to see a supply or DME item when manipulative or non-manipulative fracture care is billed, it is not mandatory. There are many times I have seen it billed but no supply or DME. The clavicle example below is one.

This issue of AAOS Now takes a look at some commonly asked fracture-related coding questions.
Using a global fracture CPT code
Q. The physician saw a patient in the office for a shoulder injury sustained during football training camp activity. Following the evaluation, the physician diagnosed a nondisplaced clavicle fracture. No cast or splint was applied. Can we report a global fracture code?

A. It is acceptable to report the global fracture code 23500 (closed treatment of clavicular fracture; without manipulation) for this service even if a cast or splint is not applied on the initial date. The global fracture code includes the work of the application of the cast or splint when performed, but the absence of such stabilization does not preclude its use.
CPT code 23500 has a 90-day global period, so it includes the work associated with the day the fracture is diagnosed and all follow-up evaluation and management (E&M) services for the next 90 days.

Another example: 27200 closed tx coccygeal fx. They might tell them to sit on a donut but usually it's just rest.
 
Yes, it comes down to the payer and the encounter documentation of each visit. It's tough to have a 100% generalized answer, it is encounter based for sure.
 
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