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Answer: Because fracture care codes (e.g., 27816, Closed treatment of trimalleolar ankle fracture; without manipulation) are considered surgical packages, follow-up treatment is included in the code and payment. Therefore, it is appropriate to append modifier -54 (Surgical care only) when the patient will receive aftercare from another specialist.
The initial emergency visit, however, most likely would not be included in the surgical package and may be coded separately. The patient would present to the ED for evaluation of an injury, which would eventually be diagnosed as a fracture (e.g., 824.6, Fracture of ankle, trimalleolar, closed). Only after this evaluation is a need for restorative treatment determined. If the fracture had previously been determined and the E/M was conducted only to ascertain course of treatment, the visit would be bundled into the treatment code. But because the E/M was performed to determine the nature of the injury, it may be billed (e.g., 99283, Emergency department visit).
To alert payers that the E/M is not bundled into the procedure and should also be paid, you should append a modifier. Using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as opposed to -57 (Decision for surgery) depends in part on whether Medicare or another insurer covers the patient.
Most fracture care services are considered major procedures, categorized as nonstarred procedures by the AMA in CPT (as opposed to starred or minor procedures). Medicare does not recognize the starred/nonstarred categorization. Instead, it assigns global periods to services. Again, because fracture care is typically considered major, these services generally carry a 90-day global period.
When reporting a nonstarred (major) service to a payer other than Medicare, append modifier -57 only if the decision for surgery is made during the E/M service. If the ED physician proceeds and treats the fracture as a separate service, the fracture care code would be reported with the ED visit code and modifier -25. Medicare requires modifier -57 when services with global periods of 90 days are performed. Modifier -25 is appropriate when services with global periods of 0-10 days are provided.
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