# Fracture care - diagnosed



## eyager (Aug 10, 2007)

Our pt was seen at er and diagnosed with a finger sprain and provided a splint and was sent to our office to follow up. Our physician saw the pt several days later and once another set of x-rays were obtained the pt was diagnosed with a finger fracture, but he did not change the splint that was initially applied by the er dr. Is it appropriate for our physician to charge the fracture care even though the er doc applied the splint?
Thanks


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## coder911 (Aug 10, 2007)

Unless your doc actually treated the fx with splint or cast, I would stay away from the procedure codes. Bill only for the E/M and any x-ray services personally provided.


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## swillard (Jul 18, 2008)

there are instances that you would not remove a splint if it would cause the fracture to shift.  He is still taking over management of that fracture so I would think he could charge for fracture care.  I would not charge an E/M because the ER sent the patient knowing it was fractured.
Susan


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## mbort (Jul 18, 2008)

I agree with Susan.  The initial dx by the er was the sprain.  The fracture was not identified until the patient was seen in the office.


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## dmaec (Jul 18, 2008)

I have to respectfully disagree with Susan and mbort - to code/bill a fracture treatment code - the fracture must be treated - via closed/open - manipulation, without manipulation - but by no means does a confirmation of an xray showing a fracture or taking over care of the fracture without doing anything - constitute a "fracture treatment" procedure code.  Which code could you even use for that?  
I agree with coder911. I'd code and E/M for that first visit - and when/if the patient follows up and fracture treatment is "really" given, (some procedure that warrants a procedure code) that's when I'd code out the initial fracture treatment code.
but that's just me


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## mbort (Jul 18, 2008)

ok--devils advocate here.

Did the doctor remove the splint to take the x-rays? 

Because the doctor does not "change" the splint (saves the ins and pt money) does not mean that he is not providing fracture care does it?

He did put the same splint back on the patient right (unless of course it was never removed for the x-ray? Did he advise the patient of the care that was needed for this fracture that was not initially diagnosed by the ER?

Would you really wait until the patient returns in two weeks for a re-x-ray and actually receives a new splint to charge for fracture care?

In the 18 years I have been coding for orthopedics, once the fracture has been identified is the appropriate time to bill for the fracture care (yes, providing treatment was rendered).  I have never waited until a return visit to charge the fracture treatment that was identified weeks ago, this is only prolonging global days etc, so in essence you are raking in on the E/M's and then capturing the fracture code at a later date.  My theory is "its now (when fx is identified) or never" for capturing the fee.

Just my two cents 
Mary


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## dmaec (Jul 18, 2008)

yes, I'm with you on that mbort -*"providing treatment is given"* ... from the info given I assumed the provider didn't remove the splint or reapply it.  Maybe I read it wrong...  You'd be correct though, if treatment was given.  However, if only the xray was done, confirmed fracture, taking over care - and no fracture treatment was given I still stand on the E/M code.  How can you code a fracture care procedure code if it wasn't done?  what code would you use if nothing was done but an xray and confirmation?  I think the patient AND the insurance company would frown upon services being billed that weren't actually given!

so, you'd  actually code a procedure code even if nothing was done?  what code would you use and how would you justify it?

yes, I'd wait however long till (if) the patient came back and had another xray - and re-splint before charging out a procedure code that wasn't really done.  More often than not, finger fracture patients usually don't return (unless they're really messed up, open fracture etc).  Initial care is usually an xray and little splint, (rarely follow doctors orders) and rarely return UNLESS it gets worse.  And if they do come back, I might only be charging out an E/M and splint application! Not fx care - depending 

of course this is my response ONLY IF fracture care wasn't given!  ONLY if all the provider did was confirm fx on xray and office visit.

if fracture care was given, of course a fracture care code or E/M splint/cast application would be appropriate


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## Treetoad (Jul 19, 2008)

I agree wholeheartedly with Donna.  If the patient is coming to our office in a splint that was provided by the ED and our provider reads x-rays that were taken by the ED confirming the fracture and our provider is not changing anything that was initiated by the ED--only continuing with the splint, I would be charging the E&M service only.  If the patient returns at all (they don't always, even if the provider expects them to), we can charge another E&M service.  If our provider was the one to initiate the splint or if he/she changed anything about the original treatment by the ED provider, I would charge fx care.  It's all a judgment call--and again, we need to remember that neither way we bill (either fx care or E&M) is incorrect.


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## mbort (Jul 19, 2008)

Its all about supporting documentation.  Unfortunately on here, the most trivial piece of documentation thats not mentioned can make or break our decisions.


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## swillard (Jul 22, 2008)

fracture care involves managing the fracture, not just applying a splint or buddy taping fingers.  If the patient is sent to us by the ER and they have already identified a fracture, we do not charge an E/M code, just the fracture care.  Maybe a splint has already been applied that we do not want removed for another week or so.  We are still taking over management of that fracture, which means if that fracture shifts, we may have to change plan of action.
If the patient comes to us and the fracture is not confirmed by the referring doctor, then we will charge an E/M and then the fracture care.

Susan


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## dmaec (Jul 22, 2008)

Susan, out of curiousity - what fracture care code would you code out then? (in your scenario below of not charging an E/M but a fracture care code instead).


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## swillard (Jul 23, 2008)

I don't have all of the information in order to give you a proper code.  However, from what I know, it would probably be a closed treatment code (it doesn't mention doing a reduction) of a DIP joint phalangeal shaft fx.  The example does not mention exactly what part of the finger.


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## dmaec (Jul 23, 2008)

Susan - right, there isn't enough information to give a proper fracture code.  Even "a closed without manipulation" code wouldn't be proper, in this case.  The info we were given was that "nothing" but an xray was done with confimation of a fracture.  
Even in the fracture care codes (for fingers any site) closed without manipulation it states that: the bones are splinted in anatomic position.  for example the 26600  is without manipulation - which simply means it does not need realignment.  However, the bones would still be splinted in anatomic position.* if *they're buddy tapped, THAT would be fracture care!
it's a whole different story *if* in the given scenario the doctor actually re-splinted/buddy taped, provided SOME sort of actual fracture treatment to the finger. *But, *it doesn't state that the doctor did anything.

(my Dad always tells me: "IF - *"ifs" *and *"buts"* were candies and nuts, we'd all have a *merry christmas*")  
So, I read what was written and I stand by what I said earlier - it doesn't appear that fracture treatment of any kind was given therefore I feel it would be fraudulent to bill/code an initial fracture care code.  I'm just saying, I wouldn't do it, documentation wouldn't support it. (no *ifs* or *buts *about it)
just my opinon


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## swillard (Jul 23, 2008)

I stand by my what I said as well. Of course, it all depends on the situation and the documentation.  As was said earlier, often times in this situation, we wouldn't charge fracture care because the patient may or may not even come back for FU.  However, I was always taught that you could.  You are still managing the fracture, you still are making a decision about what needs to be done.  That's why every situation needs to be looked at independently based on the documentation.  
What about this?  If a patient comes from the ER with a proximal humerus fracture.  Pt is in a long arm splint.  My doctor does not remove it on that first visit, but is seeing the patient back in a week.  We did not remove the splint on the first visit.  On the second visit, we removed the splint and put her in a long arm splint.  I don't wait until the 2nd visit to code the fracture care.  We are still taking on the management of that fracture.  We simply waited until the swelling decreased.  I charge fracture care at that first visit, then application of a cast on the second visit along with 99024


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## dmaec (Jul 23, 2008)

swillard said:


> I stand by my what I said as well. Of course, it all depends on the situation and the documentation.  As was said earlier, often times in this situation, we wouldn't charge fracture care because the patient may or may not even come back for FU.  However, I was always taught that you could.  You are still managing the fracture, you still are making a decision about what needs to be done.  That's why every situation needs to be looked at independently based on the documentation.
> What about this?  If a patient comes from the ER with a proximal humerus fracture.  Pt is in a long arm splint.  My doctor does not remove it on that first visit, but is seeing the patient back in a week.  We did not remove the splint on the first visit.  On the second visit, we removed the splint and put her in a long arm splint.  I don't wait until the 2nd visit to code the fracture care.  We are still taking on the management of that fracture.  We simply waited until the swelling decreased.  I charge fracture care at that first visit, then application of a cast on the second visit along with 99024


Susan - yes, each situation is unique, I was going by the info given. For the info you've given; I wouldn't have coded your scenario as you did . I would have coded an E/M first visit - and on second visit the fracture care. I mean, we could get into all sorts of "what ifs" - did ER code fx care? (sometimes they do) I'll assume not - How did you know for sure that your patient would come back to you? Perhaps they'd move, or were just visiting and went back home, maybe sadly, they'd die -and never make it back to see your provider!  I only code fracture care when the provider actually does fracture treatment. Otherwise it's an E/M.  Simply taking over management of a fracture treatment doesn't give "that" provider an automatic initial fracture treatment code to bill/code out.
that's my 3 pennies


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## mbort (Jul 23, 2008)

Here is some guidance from the AAOS that was kindly posted by another AAPC member in another thread.

http://www.aaos.org/news/aaosnow/jul08/managing2.asp

Coding for closed treatments of fractures
By Mary LeGrand, RN, MA, CCS-P, CPC; Margaret Maley, BSN, MS; Robert H. Haralson III, MD, MBA; M. Bradford Henley, MD, MBA; Matthew Twetten, MA

Coding for closed treatment of fractures is controversial; this article provides suggestions on how to code for this form of treatment. Closed treatments are either with or without manipulation. An orthopaedic surgeon has the following two ways of coding closed treatment of a fracture under Current Procedural Terminology (CPT):

“Global” reporting of the services by using the 90-day, global fracture code with or without reporting the initial evaluation and management (E&M) service that resulted in the decision for closed treatment, or 
“Itemized” reporting of the services by reporting each patient encounter separately. The physician reports each service independently and does not enter into a 90-day global period. 
The AAOS position is that the orthopaedist must have the option of coding these services either way to enable the treating surgeon to address the specific situation and to meet the physician’s contractual obligations with payors. 

Charging a single, all-inclusive large global fee may seem excessive to a patient, especially if the patient doesn’t understand that the charge includes 90 days of physician E&M services related to the fracture. Other times, insurance companies may pay for emergency visits (for example, a global fee with limited patient financial responsibility) but may not pay for office visits, or vice versa. Some insurers require high copayments for office visits, while others apply a coinsurance to the global fracture service. In these situations, a patient may express concern about the financial cost of one method or the other. The physician should report the method that best addresses the situation, meets the physician’s contractual obligations, and complies with coding rules. 

The Centers for Medicare and Medicaid Services (CMS) does not have a preference for coding closed nonmanipulative fracture services. Processing a single global claim for 90 days of care may be less expensive for the government, insurance companies, and physician offices than submitting and processing multiple claims (during 90 days of fracture care) and adjudicating disputes resulting from appeals to claim denials.

Because CMS does not give coding advice, it has not given specific directions for reporting closed treatment of fractures. In 2003, however, CMS issued a directive about adjudication of claims stating that carriers will not allow the total compensation for fragmented (eg, itemized) coding to exceed the total compensation for comparable global coding. 

Additionally, in recent years, CMS carriers (such as Rhode Island and Kentucky) have asked for a refund when investigating a patient complaint resulting from a large financial responsibility after a physician had charged for nonmanipulative fracture “surgery.”

Global and itemized options
When using the global method, code for the procedure, which invokes a 90-day global period. All subsequent E&M services related to the fracture are covered by the global fee as well as the application of the first cast or splint. The original E&M service may be coded with a modifier (such as 57 or 25), depending on the level of the encounter. If the encounter is minimal, which it may be for evaluation of an isolated injury, do not code for the encounter. Many payors will not pay for an encounter code in this situation. 

When using the itemized method, report the initial services by the physician or nonphysician provider (physician assistant, nurse practitioner, or clinical nurse specialist) with the appropriate codes, as follows:

E&M for the first visit—9920x-25 for a new patient office visit, 9921x-25 for an established patient office visit, or 9924x-25 for a consultation provided in the emergency department (ED) or in the physician office. The modifier 25 is necessary to show that the E&M service is a significant and separately identifiable service because it is associated with a procedure (application of a cast or splint). If the service is provided in a setting other than the office or ED, report the appropriate category and level based on the place of service and append modifier 25. 
Application of an initial cast or splint (assuming that the physician or supervised staff employed by or under contract to the physician applies the cast or splint) 
Supplies for casting/splinting, if applicable, depending on the place of service 
Subsequent services are reported as follows: 
E&M services using established patient visit codes if the services are provided in the office (9921x), or other E&M code that is specific to the service setting 
Application of replacement cast(s) or splint(s), assuming the physician or supervised employed or contracted staff applies the cast or splint). Add modifier 25 to the appropriate E&M code if it is a “significant and separate service” provided in addition to the procedural service (such as application of the cast/splint). 
Supplies, if applicable, depending on the place of service
When is closed treatment of fractures reported?
Closed treatment of fractures is commonly reported in two scenarios. One is when the injury requiring nonmanipulative treatment is the only procedural service performed by the physician (Example 1 and Example 2). 

As these examples show, the reimbursement is about the same, but different methods are advantageous for different situations. Itemized reporting requires the physician to have supporting documentation and medical necessity for the E&M service at each subsequent visit. No specific E&M documentation is required for subsequent visits when fractures are reported using the global fracture codes. The orthopaedic surgeon should have the flexibility to vary the way fracture care is coded to allow what is best for the patient and society. 

Closed treatment of fractures may also be reported within the global period of another procedural or surgical treatment (for example, during the same hospitalization as the open treatment of another fracture or injury such as anterior cruciate ligament [ACL] repair). This commonly occurs when a patient has sustained multiple injuries or fractures or has sustained a new fracture within the global period of a prior service (patient slipped and fell while using crutches after an ACL repair). 

Situations involving the closed treatments of fractures that occur concurrently or within the global period of another procedure or surgical treatment most commonly arise when caring for patients with multiple injuries, one of which is a fracture requiring a closed treatment.

Example 3 shows reporting for an elderly patient who fell and sustained an intertrochanteric proximal femur fracture (treated with an intramedullary implant) and a clavicular fracture (treated closed without manipulation). It assumes that the patient was evaluated in the emergency department (ED) on the same day that both her intertrochanteric fracture was stabilized surgically and her clavicle fracture was treated without manipulation. 

Reporting by an ED physician
Another problem in reporting the closed treatment of fractures is the confusion about how an ED physician should code for nonmanipulative fracture care when he or she was the only physician who saw the patient in the ED. On occasion, the ED physician has used a global fracture care code for the application of a splint/cast, and then referred the patient to an orthopaedist for follow-up care. In such a situation, the orthopaedist is unable to receive reimbursement for the care provided.

CPT suggests that only the physician who provides the “restorative” treatment and is “responsible for the initial cast, follow-up evaluation(s) and the management of the fracture until healed” should use the global code. The proper coding is for the ED physician to code for the ED visit and application of a splint if appropriate. 
If manipulative fracture care that meets the definition of “restorative treatment” is provided by an ED physician and the ED physician has provided a “significant portion of the global fracture care,” the ED physician may use the global code with modifier 54 (surgical care only). However, this treatment must meet the “restorative” care definition and should not be merely splinting a fracture after straightening the limb. 

According to CPT, the following reference supports reporting the services using an E&M code and the appropriate cast/splint application code as applicable. “If cast application or strapping is provided as an initial service (eg, casting of a sprained ankle or knee) in which no other procedure or treatment (eg, surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code (99070) in addition to an evaluation and management code as appropriate.” Supplies would be reported using the appropriate A (nonMedicare) or Q (Medicare and other payors requiring Q) codes.

Mary LeGrand, RN, MA, CCS-P, CPC, and Margaret Maley, BSN, MS, are consultants with KarenZupko & Associates. Robert H. Haralson III, MD, MBA, is AAOS director of medical affairs. M. Bradford Henley, MD, MBA, is a member of the AAOS Coding, Coverage, and Reimbursement Committee; Matthew Twetten, MA, is senior policy analyst in the AAOS department of health policy and governance initiatives.

If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org


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## abevan (Aug 1, 2008)

*no what*

I have a patient who has a cuboid and a navicular fx. He came to the office saw one of the Dr. they advised treatment as clsd with no reduction said if the patient did not heal he would have to have surgery. Patient came back for follow up and on his 3rd follow up the DR. that was treating him clsd reffered to another DR. in the practice to do a ORIF of the cuboid. I billed out the clsd treatment for the cuboid and the navicular and then did the ORIF with a 58. Is this correct?????


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## mbort (Aug 1, 2008)

I would use a 78 modifier.  The doctor did not plan on taking the patient to the OR therefore it is an unplanned event, not staged.


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