Orthopedic Coding Alert

Question: What is the correct way to code for fractures that are treated without castings? Do I use fracture treatment codes or charge for an evaluation and management (E/M) visit instead?

Nebraska Subscriber

Answer: The simple answer is to bill just the E/M code. This is especially true if you are likely to see the patient only one time. Reimbursements on the global fracture care codes may come out lower than E/M reimbursement when the patient is seen on multiple occasions, and therefore there is often no advantage to reporting the fracture care codes.

To get a true answer, you need to look at what you are paid for different fractures, along with x-rays, any followup visits and casting supplies to determine the best fiscal route. Bear in mind that many HMOs will require that the patients first see their primary care physician, who will then issue a referral to an orthopedist for fracture care. In cases like this, they will probably only pay the orthopedist for a fracture code, rather than for an E/M code. Check the patients referral to determine what services have been authorized.


You Be the Coder and Reader Questions answered by Heidi Stout, CPC, CCS-P, coding and reimbursement specialist at University Orthopedic Associates in New Brunswick, N.J.