Fracture Codes/ Office Visits


bloomington il
Best answers
Has anybody got any thoughts on when is it appropriate to bill and Fracture Code and Office visit on the same day? Example, If the Dr sees the patient for ankle fx. Commercial insurance, Bcbs, Health Alliance. Do you use a modifer? separate dx?

thanks, Lisa
Fracture code

Is this fx trmt being done in ofc? If so you could use modifier 25. however if doc is seeing pt and then going to hospital to do surgery you would want to use modifier 57
thoughts on OV w/ fx's & inj's

Hi! I have been working for an Ortho group for 5 yrs now and also taking a refresher course where my teacher is also and auditor and from what I am understanding from her is:
It depends on what the patient is being scheduled for, or what the appointment is being set up as, for example. If the patient is scheduled for a confirmed fracture then we should use caution on charging the OV as well as the fx care and also when the patient is also scheduled for injections.
Now if you have a patient that is coming in for lets say pain in wrist and the fx has not been confirmed yet and we do x-rays and confirm the fx at that initial visit then we could bill the E/M as well as the fx fee with a 57 mod on the E/M.
I was also told to look to CMS and OIG for documentation and guidelines to actually have something in writing to support the findings.
Hope that helps because it can be confusing as to what the correct way to handle this issue and some of the information I have found has been contridicting on which way to do this!
If anyone has any other ideas or suggestions I would like to hear back on this issue as well.

Fracture care is one of those highly discussed and debatable issues. It really needs to be a policy established practice by practice as there are technicaclly two methods of billing fracture care. The first method is when the non-manipulative fracture care code is billed it covers the patient for all care for 90 days, unless they have to have an ORIF. The second method is to bill individually by encounter a separate E/M. This method is easier for some patients to grasp. Both versions are correct.

I have worked with physicians that never bill non-manipulative fracture care codes as they are hard for patients to understand that they are billable when they "don't do anything in the office." Patients will claim "he didn't do any surgery, this is outrageously expensive...fraud (and everything under the sun)." They just don't realize that this is the most economically form of billing vs. getting a charge for each visit.

If the practice does definitive care, this includes coming up with a plan, xrays, pain managment and providers are entitled to bill fracture care. E/M is not part of these CPT codes, they are considered a major procedure (bundled) and billable separately. A mod-57 should be appeneded to the E/M, never a 25 due to the 90 day global period. Mod-57 is for major procedures and mod-25 is only for minor procedures.

Depending on the point of service, ER vs office, the question becomes is the doctor treating or stabilizing the fracture. If the physician is stabilizing the fracture without manipulation and then refering the physician to say an orthopedic physician for definitive treatment - they would not charge for fracture care. If the physician is performing definitive care and coming up with a treatment plan he is entitled to bill fracture care. The exception to that rule would be if the physician determines the patient needs an ORIF then append a mod-57 to the E/M even if it's within 3 days of surgery, without billing fracture care at that encounter.

There are times where the physician does not see that an ORIF is needed at the initial encounter, but maybe two weeks later during a followup visit the bone(s) are not healing correctly and a ORIF is needed. It would still be appropriate to bill for fracture care from the first visit and append a mod-78 to the ORIF if done by the same physician. This will not decrease the reimbursement to the provider, but it does restart the global period from the date of ORIF surgery.

It all depends on how the individual practice wants to set up their protocol.