Wiki unbundling fracture care codes

[deborahcook4040]

Hi.

I have a new physician in my practice who refuses to use any fracture care codes because they have a 90 day global period. He says that they're not a surgical procedure and he makes more money billing out the E&M and casting codes seperately than he does using fracture care codes (which is probably the point of fracture care codes, actually). I think this is unbundling, but how do I prove that to my physician (assuming it's true)?

Thanks,

Debby

 

[mitchellde]

For non displaced fractures you can bill it either way. Either use the global code or bill ov with the cast code, it is called fracture alternative billing.

 

[tjrice]

Depending on the payor, they may downcode to HCPCS cast supplies including application and pay the lesser of the two if E/M code is used also. He could be opening himself up to a knock on the door from a federal/state audit.

 

[deborahcook4040]

well, here's a few links I found helpful:

http://www.aaos.org/news/aaosnow/jul08/managing2.asp & http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf & http://news.aapc.com/index.php/2012/10/fractures-101-lets-cover-the-basics/

Here's the applicable paragraph from the 2000 pg Medicare manual link above:


40.4 - Adjudication of Claims for Global Surgeries
(Rev. 1, 10-01-03)
B3-4824, B3-4825, B3-7100-7120.7
A. Fragmented Billing of Services Included in the Global Package
Since the Medicare fee schedule amount for surgical procedures includes all services that are part of the global surgery package, carriers do not pay more than that amount when a bill is fragmented. When total charges for fragmented services exceed the global fee, process the claim as a fee schedule reduction (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 surgery allowed amount). Carriers do not attribute such reductions to medical review savings except where the usual medical review process results in recoding of a service, and the recoded service is included in the global surgery package.
The maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure.
In addition, the limitation of liability provision (§1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care.


Now... who wants to come convince my doc for me?