Part B Insider (Multispecialty) Coding Alert

But pay attention to the physician's intention

Two right ways to bill, and the differences could be subtle -- or dramatic.
 
It sounds like a coder's nightmare, but in fact the ongoing controversy over billing for non-manipulative fracture care using a global code (with a 90 day global period) or itemized billing isn't too terrible.
 
The RVUs for global fracture care and itemized coding usually work out the same ccording to a presentation by Ellensburg, WA coding consultant Margie S. Vaught at the 2004 American Association of Professional Coders conference.

For example, you could bill for one evaluation and management service using CPT 99213 -57, then bill either 25500 (including cast) or 29075 (initial casting plus two). After that, in the itemized approach you'd bill for three E/M visits (99213) or two cast applications (29075). In the end, the units wind up being slightly higher for global coding (12.25 versus 11.35), but the difference isn't great.

However, in some circumstances the difference between global fracture care and itemized billing can be much greater. For example, if you know that a patient will be coming back regularly, it can make sense to bill on an itemized basis because those E/M visits will add up.

"It's kind of a judgment call," says Alameda, CA podiatrist Anthony Poggio. "If you get a sense that the patient's very compliant," and will follow advice, then go ahead and bill global. But for a non-compliant patient, who's going to get the cast wet or walk on it, it's better to bill itemized. "Some fractures by their nature are stable," but others you know right away may need more surgery or office visits. "Sometimes you lose, sometimes you win," says Poggio. The worst patients are the active ones with children or a job that keep them rushing around.

The average number of visits after a non-manipulative fracture repair is three or four, says consultant Annette Grady with Eide Bailly in Bismarck, ND. But your practice should look at its own records to determine the average number of visits for its population. For a hand surgeon, it's almost never going to work to bill global fracture care codes, because hand fractures usually require a lot of followup visits, says Grady.

Rather than making the decision on a case-by-case basis, Grady encourages practices to choose one way or the other for good. "The practice needs to decide from the very get-go which way they're going to do it, not switch back and forth," she insists. The exception is if most of your patients require only a few visits, but you have one patient who needs closer monitoring. Usually the challenging patients and the easy patients balance out, however.

The newer ergonomic splints made of fiberglass don't need to be replaced nearly as often as older casts, so you won't likely need to bill for too many followup cast applications, notes Grady. The good news is that X-rays are always separately payable with either method of billing.

In choosing between a global fracture care code or an itemized approach, it's also important to pay attention to the physician's intention. If the physician intends to take responsibility for the patient's management from beginning to end, then you may want to bill a global code in any case, say some coding experts.