Coding guide for CPT Fracture Care in ED facility

Most of the fracture cases are coded in emergency department (ED) facility, hence it is important to understand the different scenarios that a coder come across for these fracture care.

Scenario 1

A patient presents to the ED after falling and fracturing his tibia. The emergency physician calls an orthopedic surgeon for a consultation.

The orthopedic physician evaluates the patient and performs a closed reduction of the tibia and applies a long leg cast. The orthopedist then takes over managing the patient’s fracture care. In this case the intent was clearly to provide full global fracture care.

The orthopedist in the above case can report the appropriate E/M visit code appended with modifier -57 (decision for surgery) to signal that the decision for surgery was made during the visit. The orthopedist may also report CPT code 27752 (closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction).

The cast application cannot be reported separately because that work is included in code 27752. Follow-up E/M care would not be billed because code 27752 carries a 90-day global period.

Scenario 2

Now let’s say a patient is seen in the ED for pain and swelling of the wrist. Three X-rays are taken.

Diagnosis: avulsion fracture, sprain left radius. The emergency physician immobilized the wrist in a splint and refers the patient to an orthopedic surgeon.

CPT guidance states that when a fracture patient is seen in the ED, the emergency physician should code their services based on two questions:

1. Has the ED physician performed any restorative treatment (e.g., manipulation of the fracture)?
2. Will the ED physician assume all subsequent fracture care during the global period? (CPT Assistant, January 2018)

In the above case, the answers to the two questions would be no. The intent of the emergency physician was to evaluate, not treat. It would not be appropriate for the emergency physician to report a fracture care code because they are not providing the full fracture care service, so the emergency physician should report the appropriate ED E/M code and splint application code.

The patient is seen by the orthopedist two days later to have the wrist examined to see if further treatment needs to be rendered. The orthopedic physician decides that the patient needs to have a new cast applied and will continue to treat and manage the patient for the wrist fracture. In addition to the wrist fracture, the patient is being seen for low back pain.

The orthopedic practice would bill the case with the appropriate new patient office visit E/M code appended with modifier -57 for the evaluation of both low back pain and the wrist fracture, including determination of the course of fracture care, and report code 25600 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) for the closed fracture care.

In a variation of the above example, say the emergency physician billed a fracture care code for his service (even if he really shouldn’t have.) He gets his bill in first and gets paid. The orthopedic practice sends in a claim for the global fracture care and gets a denial as a duplicate claim.

The orthopedic practice in this case should send in appeal letters to the payer stating that in fact the orthopedist performed the global fracture care service, not the emergency physician. The carrier should then recoup the emergency physician’s reimbursement and process the claim correctly, paying the orthopedist for the global care.

Modifiers

When two different clinicians provide the definitive fracture treatment and the follow-up care, modifiers -54 (surgical care only) and -55 (postoperative management only) should be appended to the fracture treatment code.

These modifiers tell the payer that the 90-day global period for the service should be split between the two doctors: The doctor that does the surgical treatment appends modifier -54, while the surgeon that provides follow-up care appends modifier -55.

That scenario may crop up when patients injure themselves on vacation, get treated nearby, and then follow up with an orthopedist closer to home.

Additional fracture care points

Cast removal

If a cast or splint is removed by a physician other than the one who applied it, report the appropriate cast or splint removal code (CPT codes 29700–29710).

Casting is the only procedure done

If a cast or splint is applied during the initial visit and no surgery is performed to treat the fracture and no global fracture care is anticipated, report the appropriate casting application code as well as the supplies that were used.

Complications that require recasting

If complications occur with the first cast or subsequent replacement is necessary, the appropriate code is selected from code series 29000–29750.

Multiple physicians

Physician applies a temporary cast or splint, another physician does the definitive restorative treatment of the fracture care, each physician may report the services provided. The physician who applied the cast would report the cast and the supplies and the physician providing the definitive treatment would report the “global fracture” code, as the January 2018 CPT Assistant explains.

Closed treatment

Closed treatment means the fracture site is not exposed by surgical incision.

Closed treatment can involve:

1. Application of a cast but no reduction because there is good alignment.
2. Treatment with manipulation to return the fracture or joint dislocation to its normal anatomic site by using manually applied forces.
3. Skin or skeletal traction that applies force to reinforce the stabilization. Skeletal traction uses force by means of a wire, pin, screw, or clamp that penetrates the bone. Skeletal traction is used with difficult or shattered pieces of bone when an open procedure cannot be performed.

Conditions that complicate fracture treatment

The word “complicated” in the code description may indicate excessive hemorrhage, infection, prolonged physician work, difficulty in reaching the site, depth of site, or tendon or nerve damage.

Percutaneous intramedullary (IM) rod coding

In recent years, CPT has redefined “open treatment” to eliminate some confusion about coding for IM rod treatments. “Open treatment” is now defined to include not only when the fractured bone is opened and visualized surgically, but also when the “fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized).” This indicates incisions made proximal or distal to the fracture site.

Referrence: https://justcoding.com/articles/analyze-scenarios-cpt-fracture-care-identifying-physician-intent