Wiki Fracture question

[ammontagano]

Patient in car accident, goes to out-of state hospital, fratured 3 toes. Patient put in Cam walker and comes to her local orthopedist for care. Ortho doc bills out toe fractures x 3. All claims deny as inclusive. If the hospital also billed the fracture charge, what recourse do we have, considering that we actually treated the fractures?

 

[mitchellde]

you do not bill out for the fracture, you can use the V54.x for the followup for healing fx, then if the hospital billed the fx care you can bill the fx care with a 55 modifier, if they did not bill fx care you can bill an office level.

 

[FTessaBartels]

Some thoughts

Scenario 1: Outside hospital actually DID provide fracture care. You are providing aftercare.
They should bill using -54 modifier; you will use same CPT with a -55 modifier

Scenario 2: Outside hospital actually only provided temporary care. You are providing definitive fracture care.
They should bill the ER code (and supplies); you will use the fracture care codes.

In any case, I would appeal with documentation proving service.

Hope that helps.

F Tessa Bartels, CPC, CEMC