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Fracture Care question

  1. Default Fracture Care question
    Medical Coding Books
    I have a question about billing for fracture care.

    The patient fell a month before being seen and broke her toe. She was referred to an ortho specialist by her family physician. The doctor did an x-ray of the toes, showed the patient where the fracture was on the x-ray, advised her that she would need to wear a post-op shoe and watch for signs of skin breakdown, as the patient is a diabetic.

    He advised that the nurse was going to put gauze in between the toes, and place the patient in a shoe. This was not done, because they did not have the right size shoe. The patient was given a bad of gauze pads to use in between the toes later.

    The physician billed for a level 3 consult, fracture care of the toe, and for the x-ray.

    I questioned the fracture care, and was told that because he was a specialist, and he looked at the foot, and since he advised the patient on what to do to treat the fracture, he was able to bill for that service.

    I guess I am confused because I have been trained to not bill for this service unless the physician actually places the patient in a stabilizing device (I guess buddy-taping in this instance?), or does something more than looking at the toe and diagnosing the fracture (which he is reimbursed for by billing the consult code). Can you give me some input, because I am curious as to how specialty specific coders/billers are doing this, and why it is different because he's a specialist?

    Thank you!

  2. #2
    Milwaukee WI
    Default I agree with you
    Ortho is NOT my specialty, but I agree with you.

    As your ortho specialist this ... If a heart surgeon listens to your heart and tells you that you need bypass surgery and how it should be done he gets to bill for the surgery even if he doesn't perform it?

    Physicians should document what they have done; coders code what was documented as done (not what was planned or recommended).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    You are correct in believing ortho specialists can bill fracture care when stabilizing the fracture is done. Which leads me to think your Doc thought the nurse did put that walking boot on patient. ? Is he aware that the correct size was not available and not given?


  4. #4
    Just because he is an ortho doesn't mean he can automatically bill fracture care codes for every fracture. Here are the guidelines. I hope they help. Ortho is one of my specialties.

    When Fracture Care Codes Apply
    You are seeing the pt for the initial visit for the injury.
    The injury is acute occurring within the last 2 weeks. One exception to this could be an undiagnosed scaphoid fracture which often takes longer to show up on the xrays
    Patient has not had surgery for this injury by another physician in a different practice.
    You plan to care for this fracture for the next 90 days.
    If the pt was seen in the ED or by another physicians office and later sent to an ortho for fracture care confer with your physician regarding billing of fracture care. Generally with orthos the pt is seen initially in the ED then they are sent to an ortho these can still be billed out as fracture care codes.

    You Shouldn't Bill Global Fracture Care
    If the fracture is old.
    If there is a non union of the fracture.
    The fracture is healed or mostly healed.
    Your doc isn't going to care for this fracture for the next 90 days.
    No follow up appt are recommended.
    Pt is scheduled for pinning or open treatment.

    If the fracture doesn't meet the criteria for fracture case use the appropriate E/M fracture with casting or splinting codes with a mod 25.

  5. #5

    I code for ortho specialists who see pt's from the ER constantly. You are correct. He did not meet the standards for closed fracture care. If she were placed in a stabilization device then yes, you could bill for it. From what you have mentioned it seems that you can only bill for the office visit and x-ray. When she comes in for a follow-up you can then bill for an established patient office visit. There will not be a global period due to the fact that there was no closed fracture care provided. I hope this helps!

  6. Default Billing for Fracture Care Guidelines
    wahmcoder ~ where did the guidelines you posted come from? AAOS? CPT?


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