# Fracture Care with E/M



## nyyankees (Dec 2, 2009)

What are the coding guidelines with an E/M and fracture care (i.e. 23600). Can you bill out an E/M? Does it depend on the documentation in the patient's file? And if so, is modifier 57 more appropriate than 25? Thanks. It's a little confusing and would like clarification. Any links to sites that have godd information is appreciated. Thanks.


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## Julie Willits (Dec 3, 2009)

No E & M with fracture care code.


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## AuntJoyce (Dec 3, 2009)

*Fracture care and E&M*

If the orthopaedic surgeon is seeing the patient for the first time, determines there is a fracture, completes the history taking and examination and then goes on to care for the fracture, you would bill:

E&M - 25
Care of fracture

You would ONLY use a -57 modifier if the decision to take the patient to surgery in the next couple of days (or longer) is made during this encounter.

Joyce


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## FTessaBartels (Dec 3, 2009)

*-57 modifier*

I agree with AuntJoyce EXCEPT ...

You need a -57 modifier. Fracture care carries a 90-day global period so is considered "major surgery" even when it's a closed reduction.

F Tessa Bartels, CPC, CEMC


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## nyyankees (Dec 3, 2009)

I actually found an artcile on Ortho-decision.com that had an article stating E/M's can be billed with fracture care - new or established pt. I found it after posting this thread. Interesting...huh?


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## HeidiLynn (Dec 3, 2009)

The CPT 23600 has a 90 day global you would use Mod 57 and you can bill E/M if the documentation supports this of course.


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## Lisa Bledsoe (Dec 4, 2009)

If the patient comes in with a known fracture (ie was seen int the ER and told to see Ortho within the next day or so), then I would only code the fracture care.


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## nyyankees (Dec 4, 2009)

Lisa Curtis said:


> If the patient comes in with a known fracture (ie was seen int the ER and told to see Ortho within the next day or so), then I would only code the fracture care.



Yes it always depends on the documentation in the record. But some of our Dr's were not 100% sure if you could at all. That's why I submitted the thread and looked for the info on AAOS and Ortho-decisions.com where I found the info.


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## AuntJoyce (Dec 4, 2009)

*Fracture care with E&M*

This is really a very debatable issue...

...Modifier 57 and the interpreted definition of major surgery...



Definition: Decision for Surgery

Use Modifier 57 when an evaluation and management (E&M) service resulted in the initial decision to perform surgery. Major surgical procedure is defined by CMS as a procedure having a 90-day global period assigned by CMS. The global period includes the 1-day prior to surgery. No documentation is required.

Modifier 57 is not eligible when used with the E&M code when the E&M visits is for the preoperative history and physical prior to the surgical procedure.


I think the issue lies mainly in interpreting major surgery...in this case, the care of the fracture, although listed in the surgery section, is truly not major or open...if the decision is for open surgery/major surgery then that is more along the lines of the definition.

Here is another excerpt...

MAJOR SURGERY- any surgical procedure that involves anesthesia or respiratory assistance
surgical operation, surgical procedure, surgical process, surgery, operation - a medical procedure involving an incision with instruments; performed to repair damage or arrest disease in a living body; "they will schedule the operation as soon as an operating room is available"; "he died while undergoing surgery"

MINOR SURGERY - any surgical procedure that does not involve anesthesia or respiratory assistance

I've about burned out my brain cells on this one...I am very interested in more opinions...


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## khalid (Dec 22, 2009)

*link*

hi can u share the Ortho-decision.com link.


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## Anna Weaver (Dec 22, 2009)

I'm wondering if we're not getting hung up on terminology. To me it's procedure vs surgery when using a 57 modifier. My understanding was that it was used for any procedure or surgery with a 90 day global period. I believe most if not all the fracture (procedure) codes are 90 day global so you would append the 57 modifier to the E/M if performed at the same time/day before fracture care. I have seen the 57 described both ways so, I think it's just a matter of how you are using it. Good discussion!


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## nyyankees (Dec 22, 2009)

khalid said:


> hi can u share the Ortho-decision.com link.



TRY THIS:

www.ortho-decisions.com/reader/article_print/167422


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## Bella Cullen (Dec 22, 2009)

Here is an article that will clear things up for people...
It tells all about what modifier and when it's ok to bill E/M with fracture care. 
Melissa 

Subject AAOS revises coding manual to OK E/M with fracture care 
Source Coder Pink Sheets: Orthopedic 
Publication Orthopedic Coder's Pink Sheet, April 2008, Vol. 9, No. 4 
Effective Date Apr 1, 2008 
Publish Date Apr 1, 2008 


The American Academy of Orthopaedic Surgeons (AAOS) has made it official: You can appropriately bill separately for an E/M visit the same day as a fracture care procedure, as long as that visit is documented to be when the decision for surgery took place.

The academy confirmed this by adding the following language to the AAOS CPT Coding for Orthopaedic Surgery 2008 manual:"..if a patient is seen for the first time, or an established patient is seen for a new problem and the ‘decision for surgery' is made the day of the procedure or the day before the procedure is performed, then the surgeon can report both the procedure code and an E&M code, using a 57 modifier or 25 modifier (payor specific) on the E&M code. The E&M service must meet the documentation guidelines for the level of service reported."

In addition, the AAOS manual now states that the E/M service is separately reportable "whether a surgical procedure is performed in the operating room or the patient undergoes a ‘closed treatment' with or without manipulation in a non-facility setting (e.g. office or emergency department)."

Separately, the American Medical Association confirmed that if the E/M service is supported (ie, it meets the required key components/counseling) it could be reported.

The following example was supplied to both AAOS and CPT/AMA: "Patient presents to office with nondisplaced Colles fracture. Provider does an expanded-focus history and examination and determines it needs closed treatment without manipulation and a cast is applied."

Both AMA and AAOS confirmed that it would be appropriate in this case for the provider to report 99202-57 or 99213-57 along with 25600, since the initial decision was made during the visit to provide a global service.

You'll want to remind your physicians to make sure to fully document the E/M visit, in order to support billing the E/M code.

In addition, AAOS reminds physicians of what is included in the global package:

"Under the global service concept, approximately 10% of a physician's reimbursement for a CPT musculoskeletal procedural service is for the preoperative evaluation and management service(s) performed the day of or day before the procedure, approximately 69% covers the procedural service and the remaining 21% covers the postoperative care, usually 90 days for a "major" procedure."

E/M code gets the 57 modifier: For the most part, the fracture treatment codes have 90-day global periods attached to them, regardless of whether it's an open or closed treatment, with or without manipulation. For Medicare, that means you'll need to attach a 57 modifier to the E/M code to get it paid, since these are considered ‘major surgery' codes.

The AMA CPT panel confirms that you should attach the 57: "An E/M service that resulted in the initial decision to perform a surgery may be identified by adding modifier 57, decision for surgery, to the appropriate level of E/M service. Depending on payer guidelines, and the payment policy for global surgery, modifier 57 may or may not affect payment." (CPT Assistant, Dec. 2004).

On the private payer side, if the insurance company recognizes the 57 modifier, it will generally allow separate pay for the E/M service where the initial decision for surgery was made. Pre-operative visits subsequent to that initial decision are generally included in the global surgery package. But be aware that payer policies vary for this modifier.

CMS confirms that for Medicare the E/M service where the decision for major surgery is made is always separately billable, too. In its Claims Processing Manual (100-04, Chapter 12, Section 40) CMS states that the following is not included in the global surgery package and is not separately billable: "The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures."

AMA on E/M with fracture care and use of modifier 57

The following clinical example, from the February 1996 CPT Assistant, illustrates the correct billing of an E/M code with fracture care:

"Patient C presents to the emergency department after falling and fracturing his tibia. The emergency department physician calls an orthopaedic surgeon for a consultation. The orthopaedic physician evaluates the patient and performs a closed reduction of the tibia and applies a long leg cast.

"In coding this example, it is important to consider that the orthopaedic physician provided a restorative treatment and is responsible for subsequent fracture care, under the surgical package. Therefore, he/she reports the E/M consultation code, provided that the key components have been met, and code 27752 for the closed reduction of the tibia. The cast application cannot be reported separately because the services described in code 27752 includes the first cast."

Also, here is the AMA position on use of modifier 57 (Decision for surgery), from the May 1997 CPT Assistant:

Modifier -57, Decision for Surgery

"An evaluation and management service that resulted in the initial decision to perform the surgery, may be identified by adding the modifier ‘-57' to the appropriate level of E/M service. Modifier -57 provides a means of identifying the E/M service that results in the initial decision to perform the surgery."

Illustration of Modifier -57

"A physician is consulted to determine if surgery is necessary for a patient with abdominal pain. The physician services meet the criteria necessary to report a consultation (ie, documents findings, communicates with the requesting physician). The requesting physician agrees with the consultant's findings and requests that the consultant take over the case and discuss his findings with the patient."

Resource:

To download Chap. 12 of the Medicare Claims Processing Manual, visit: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

The information contained herein was current as of the publication date. © Copyright DecisionHealth, all rights reserved. Electronic or print redistribution without prior written permission of DecisionHealth is strictly prohibited by federal copyright law.


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## harmijo (Jul 28, 2011)

*Shoulder xray*

does an E/M apply if a shoulder xray was done during an office visit?  patient was seen for her shoulder pain ONLY.


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