Orthopedic Coding Alert

Fracture care is one of the most complicated procedures to code. Coders continually question whether they should report a global fracture treatment code or an E/M services and casting code. Further complications arise when one physician performs the initial fracture treatment and another physician assumes responsibility for the follow-up treatment.

Upon closer inspection, a reader question and answer from the April 2001 Orthopedic Coding Alert (Fracture Without Castings, page 32) did not fully address this complex issue. Michelle Logsdon, CPC, CCS-P, billing manager and compliance officer at Ocean Orthopedic Associates in Toms River, N.J., wrote that our response to the question was unclear. The response advised practices to code for the highest reimbursement, depending on how many times the patient will return, Logsdon says. Billing for E/M services because you will get paid higher overall for the amount of visits should not determine how you code.

Logsdon reasons that a nondisplaced fracture, when manipulation is not necessary but casting is, should be billed as a treatment of fracture. As with fractures that do not need casting, we still bill for the treatment of that fracture, she says. I find it easy to explain to my patients that the treatment for the fracture is the doctors decision. If the orthopedic surgeon felt a cast was not needed, as in a nondisplaced metatarsal fracture, and just a firm shoe was required, that is his decision as to the best form of treatment.

The answer to the original question was incorrectly attributed to our consulting editor, Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J. Stout agrees that the original answer was not thorough.

A lot of coders questions about fracture care can be answered by carefully reviewing the instructional notes that appear at the beginning of the musculoskeletal system section (20000-29909) and the application of casts and strapping (29000-29750) section of CPT 2001, Stout says. The instructional notes that precede the codes in the application of casts and strapping section of CPT state, The physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

By reporting a global fracture care code, you are billing for a package of services. This package includes the initial treatment of the fracture with or without cast application and all follow-up visits related to treatment of the fracture for a 90-day period from the time of the initial encounter. Any recasting during the 90-day period can be reported separately using one of the codes from the application of casts and strapping section. X-rays taken in the physicians office during the global period can also be reported. Removal of the initial cast is included in the global fracture treatment code and is not to be reported separately. Therefore, if a physician is applying the initial cast and assuming all of the subsequent fracture care during the 90-day global period, he or she should report one of the global fracture treatment codes.

The American Academy of Orthopedic Surgeons (AAOS) supports this approach when reporting services related to the treatment of fractures but also offers an alternative method of reporting in cases when fracture treatment does not include a procedure, such as closed treatment without manipulation. Under these circumstances, services can be reported in an itemized manner. Specific examples and further instruction can be found in the AAOS Guide to CPT Coding, which includes an informative section on surgical and fracture global fees.

Splitting global fracture care between two physicians raises another important reimbursement dilemma. In this situation, the physician who renders a large portion of the global fracture care package for instance, performing a closed reduction of a displaced fracture should report a global fracture care code with modifier -54 (surgical care only). The physician who follows the patient during the 90-day global period would also report the same global fracture care code with modifier -55 (postoperative management only).

Although somewhat uncommon, this treatment scenario occurs when a patient suffers an injury while away from home, receives acute fracture care and returns home for follow-up treatment. This method of reporting requires coordination and cooperation between both physicians offices for each provider to be reimbursed correctly. If the physician who provided the initial treatment fails to append the appropriate modifier to the global fracture care code, the physician who provides the follow-up care will not be reimbursed for his or her services.

Orthopedic coders should not be without the following two resources, which offer much guidance on fracture care coding and other important issues:

AAOS Guide to CPT Coding. The guide can be obtained by contacting the American Academy of Orthopedic Surgeons at 800-626-6726 or custserv@aaos.org.

CPT Assistant Archives 1990-2000. Available on CD-ROM by contacting the American Medical Association at 800-621-8335 or www.ama-assn.org/catalog.