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Fracture Billing Guidelines

  1. #1
    Smile Fracture Billing Guidelines
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    If a patient is treated in the office for closed reduction of fracture, splinted
    and put on the surgical schedule for open reduction in say 2 to 4 days, is
    billing closed reduction for the office visit and then the open code when
    the surgery is done with a 58 modifier, or is it more appropriate to bill
    an E&M with 57 modifier and bill the splint for the office visit and then bill
    the open code for the surgery.
    I find no real clear guidelines on this.

  2. Default fracture billing
    I would code an E/M with the 57 modifier and bill for the splint that was applied.

  3. Default
    Quote Originally Posted by TinaG View Post
    If a patient is treated in the office for closed reduction of fracture, splinted
    and put on the surgical schedule for open reduction in say 2 to 4 days, is
    billing closed reduction for the office visit and then the open code when
    the surgery is done with a 58 modifier, or is it more appropriate to bill
    an E&M with 57 modifier and bill the splint for the office visit and then bill
    the open code for the surgery.
    I find no real clear guidelines on this.
    It would just be E&M code and the supply. No modifier unless surgery was done that same day or the next day.
    You can't bill fracture care if the pt is scheduled for surgery days later and they decided this on that day of the Office visit. That would be over billing.

  4. #4
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    E/M with 25 modifier and application of splint since surgery was scheduled. You should (hopefully) be able to capture a higher level of service..if the documentation supports it of course, but definetly not fracture care.

    Mary, CPC, COSC

  5. Default
    My understanding is you cannot bill for the application of the cast/splint for that office visit before surgery because in the CPT book it says: A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.
    So you could only code the E&M and the supply HCPCS code for this specific case.

  6. #6
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    Since there is no fracture care code being billed on the initial visit, that would not apply. That is if the fracture care is done on the same date of service as the splint/cast.

    Mary, CPC, COSC

  7. Default
    You wouldn't bill for fracture care in the office if the provider is planning to take the patient to the OR for surgical repair of the fracture.

    ~L
    CPC, CGSC, COSC

  8. #8
    Default
    If the Dr performed the "closed reduction" in the office, wouldn't you capture that procedure? I agree with Not billing for Fx care if sx is scheduled that visit, however, if the physician actually performs a closed reduction I would bill the CR code. Any thoughts?

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