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Fracture Coding

  1. Default Fracture Coding
    Medical Coding Books
    I have a patient that was seen in our ED for poss fx. Patient was put in a splint for his fx and told to follow up in the clinic. Patient is evaluated in the office and it is decided to leave him in the splint until the swelling goes done. The patient is told to come back in four more days for casting. Would I wait and start the fx care on the casting day or would it start on the day of the first evaluation?


  2. #2
    Duluth, Minnesota
    I would wait - yes...because, that patient might NOT come back. He may end up in ER again, with problems, may end up at another provider. Too many things could happen that "might" prevent that patient from returning to your provider. I would not code the definitive fracture treatment code UNTIL the doctor actually provides it. The global period will start when the fracture treatment is provided.

    that's just me...others will disagree I know..
    Donna, CPC, CPC-H

  3. #3
    I disagree. I would code out the fracture at the time of the initial evaluation since the patient has been advised of treatment of this fracture and a return appointment has been scheduled. The treatment plan for the fracture care has been rendered on the initial evaluation and therefore should be billed as such.

    Mary, CPC,COSC

  4. #4
    Duluth, Minnesota
    on the same line of thinking then: if I go to the doctor, and they set a treatment plan for a ohhh, lets say a pap in 4 days or a lesion removal "tomorrow" (not today because they have an emergency, or I have to go - whatever, just no time today) BUT in 4 days (or tomorrow) we'll do it........does that mean they should charge for that pap/lesion removal "today" because they plan on doing it in 4 days (or tomorrow)? Heck, I could get in a car accident on the way home and die - never make back there for anything!!!!

    the provider says, we'll wait till the swelling goes down before we cast it come back in 4 days we'll see how you're doing at that time... the patient might decide at walking out - that "hey, I think I'll go to a different doctor - not back to this guy (for whatever reason)...the next doctor, the one that provides the fracture treatment, is the one that should be coding/billing it. Not the one that "plans" on it in 4 days. IF he codes it, and the patient goes to a different doctor THAT doctor will be coding/billing it and the first docs coding will be incorrect/flat our wrong - for services not yet rendered. (but plan on 4 days)

    again...just my take on this and understanding of correct coding and who should get the fracture treatment code and when......

    I see what your'e saying Mary - I just disagree...but I think we disagreed on this very issue before too!
    Last edited by dmaec; 04-28-2009 at 02:57 PM.
    Donna, CPC, CPC-H

  5. #5
    I will post a couple of sources from which I use to make my decision for the poster to review and make the decision based on resources from other professionals:

    This was posted on the decision health ortho list serve just a couple of weeks ago (you will have to read through the e-mail, Margie Vaught's response is there are well:

    In a message dated 4/13/2009 5:39:52 A.M. Pacific Daylight Time, writes:
    We have two PA's in our office that went to a seminar and were told it was fraudulent to not bill fracture care when there was an established fracture. I emailed the conference presenter and following are her comments. This is the first time that I have heard this. I would like feed back from anyone else regarding this. I would also like concrete evidence that billing visits and not fracture care is fraud.

    Below are the questions I asked and the conference presenters responses. I have highlighted her responses in yellow.

    Two of our PA's attended the conference you gave on April 7. They came away with an answer I am not sure they understood. I want to clarify this.

    If the patient comes in for a non-displaced fracture and we do not charge fracture care, this is fraud? Is that correct? Nothing that I have ever heard in any of the seminars I have attended, have I ever heard this.

    Here is the problem (that could be considered Fraud), if there is a CPT code that relfects the are provided and that CPT code is not used because of financial issues this is where the below may come into play. And yes, I have had an ortho get into trouble with both BWC and Anthem on this. Misrepresenting the services rendered (upcoding or the use of procedure codes not appropriate for the item or service actually furnished), amounts charged for services rendered, identity of the person receiving the services, dates of service, etc..Is there anywhere I can get documentation of this? A lot of times when the doctor knows they are not going to follow the patient for 90 days, such as metatarsal fx, metacarpal fx, etc.

    On the Medicare (Palmetto web site) under the Physician/Supplier Guide go to the "Fraud" section and read the pieces parts

    As I told your PA's for BWC we must code the fracture care because of the BWC implications for their patients, disability and long term issues.

    If one does not "immobilize the limb" then fracture care may not have occured thus an E&M might be acceptable, but when one splints, casts, or immobilized then this becomes an area of potential risk.

    Thanks for your help in getting this matter straightened out.

    This was Margie Vaught's response on 4/13/09 : She states

    "It is true that if there is a given procedure and a code, technically you are to report, but you will find below several Medicare carriers/payers that talk about itemized reporting. AAOS has stated that more and more some private carriers/payers are now requiring the use of global coding."

    Medicare Part B Bulletin #237: Noridian - MAC J3 - MAY 07
    Publish Date May 2007
    States Affected AZ MT ND SD UT WY
    Subject Coding for Definitive or Restorative Treatment of Fractures

    Noridian Administrative Services (NAS) has been asked how to code for definitive or restorative treatment of fractures. Several options are available for appropriate coding and billing.

    ? If the initial treating physician is not providing the follow up care of the fracture, the appropriate global fracture care code from the 20000 series of codes [e.g., 25500 (treatment of fracture radius)] may be used with modifier 54 (Surgical Care Only).

    ? Alternatively, when the initial treating physician is not providing the follow up care of the fracture, one or more of the following codes may be used in place of the global fracture care code:

    An evaluation and management (E&M) code.

    A casting, splinting, or strapping code.

    When all of the follow up care for the 90 day global payment period is provided by the same second physician, one of the following two options may be used:

    ? Use the same global fracture care code as the initial treating physician with modifier 55 (Postoperative Management Only).

    Use either an E & M code or a casting, splinting, or strapping code for each follow up visit.

    When only part of the follow up care is provided by a second physician, a global fracture care code should not be used and either an E & M code or a casting, splinting, or strapping code may be used.

    ? When the attending physician initiates the care of the fracture and also provides all of the post operative care of the patient, either following their own initial evaluation or on referral by another physician, he/ she may bill the appropriate global fracture care code from the 20000 series without a modifier.

    Please note that the following coding guidelines may apply to some or all of the above scenarios:

    ? When the global fracture care code is used, an E&M code with modifier 25 may not be used unless modifier 25 criteria are met. (Significant, separately identifiable Evaluation and Management service by the same physician on the same day of the procedure or other service)

    ? When the global fracture care code is used an E & M code with modifier 24 may not be used unless modifier 24 criteria are met (Unrelated Evaluation and Management service by the same physician during a postoperative period)

    ? An E&M code with modifier 25 may not be used in addition to a casting, splinting or strapping code (29000-29550 and 29590) unless modifier 25 criteria are met.

    ? The appropriate cast supply code (Q4001-Q4051) may be billed only when the physician is supplying the cast supplies (e.g, in the physician's office), and should not be billed in the emergency department or other facility place of service (e.g., emergency room or hospital).

    ? When the sole reason for the follow up visit is to replace the previously applied cast, splint, or strap, the physician may bill either an E&M code or a casting, splinting, or strapping code.

    ? The allowance for application of a cast, splint or strapping includes removal or repair by the same physician or other physician in the same group. Billing for cast removal or repair (29700-29750) should be employed only for casts applied by another physician group.

    ? Noridian Administrative Services (NAS) has noted that providers have been advised by some coding sources to report a splint application code for the application of “off the shelf” or pre-packaged splints.

    While it may be appropriate to bill for the actual splint, NAS strongly disagrees with the advice to bill separately for the application of these splints. The application of the pre-packaged splint is a bundled service when performed on the same day as an Evaluation and Management (E&M) service or other procedure and may not be separately billed.

    Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY."

  6. #6
    Duluth, Minnesota
    In Ramsey's scenario - the provider "left it alone"...they didn't apply the splint, the splint was already applied in the ER. He was told to come back for the actual cast application/fracture care. (and again, my problem here is, the patient might NEVER make back for that service so it should NOT be charged/coded until it's provided)

    I do have the same info you posted, (as well as other info) and I think it explains the use of fracture care codes very clearly. After reviewing it and other info I have on fracture care, I feel even more confident in my response to wait for the return of the patient for the actual fracture treatment to that provider before billing/coding it out. For "this" visit, I would code as the appropriate E/M level. The provider has plans for the patient to come back, but they are just "plans", the patient might not come back.

    I agree with (most) of the post. In some cases the use of the modifiers 54/55 are definately needed, E/M's should be coded as opposed to fracture treatment (at times), etc...An area of that post I disagree with is, I believe they're incorrect in the modifier useage... requiring 25, if using fracture care would be the use of 57 (because the fracture care codes have a global of 90 days not a 10 day) and of course only if the modifier 57 criteria are met.

    Mary, I respect your opinion and I know we disagree on this topic (we have before) So I'm thinking we should just agree to disagree on how we'd code the scenario that Ramsey posted.... and let Ramsey decided from here
    Donna, CPC, CPC-H

  7. #7
    Milwaukee WI
    Default An analogy
    An Analogous situation: We have Plastic Surgeons that respond to a request from the EDTC physician to see a patient with facial lacerations. They will clearly document their E/M and in the plan will state something on the order of "will suture laceration."
    Now, I know that they actually performed the repair because a few days later the patient comes back to clinic for a "no charge F/U visit & suture removal" ... BUT ... we don't code the laceration repair because they don't document it. They only documented that they "plan" to do it.

    That's how I see the scenario presented. Granted we don't have all the documentation, so perhaps Ramsey's description of the case is not totally accurate. But let's just assume that Ramsey's description is exactly what he says it is. The patient came to the clinic as directed, was evaluated, but the fracture care wasn't provided yet. There's no manipulation. There's no casting. They are "leaving him in the splint until the swelling goes down." There's just an eval.

    I'd wait to code the fracture care when it was actually provided, on the next visit.

    Just my opinion,

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 04-29-2009 at 02:37 PM.

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