Pediatric Coding Alert

Question: Our office has an after-hours facility that treats acute illnesses and non-complex injuries after hours and on the weekends. We see mostly our own patients; however, we do offer our ervices to other providers' patients in town so they can avoid the emergency department prices if possible.

• Bill global fracture care with modifier 56 (Preoperative management only) -- showing that we are performing the preoperative management only, and that a different provider will handle the procedure and follow-up care?

Colorado Subscriber

Answer: While you could itemize the charges for all cases, you should use the global fracture care with modifier 56 option only if your physician provides the nonmanipulative treatment and places the initial cast/splint. The global fracture care code's preoperative management portion (modifier 56) includes both the treatment and the initial cast/splint. Modifier 55 (Postop-erative management only) is for the follow-up care for the 90-day global period.

Alternatively, you could report these visits with the office visit code, the splint/cast application code, and the X-ray. The American Academy of Orthopedic Surgeons (AAOS) leaves the coding method -- fracture global fees or alternative fracture fees -- up to the provider and recommends focusing on the visit's intent. "That intent may consist of the provider performing what he/she believes is more of an evaluation and management service and not so much a global fracture care service," according to the AAOS June 2002 bulletin.

You mention that in most cases, the cast is placed at a later date -- and your PCP places a temporary splint/cast/sling. Since an outside PCP will provide the definitive fracture care and place the initial cast, a global fracture care code (such as 25500, Closed treatment of radial shaft fracture; without manipulation) more appropriately captures that visit. "A temporary cast/splint/strap application is not considered to be part of the preoperative care, and the use of modifier 56 is not applicable," according to CPT's Application of Casts and Strapping guidelines.

You would use the alternative fracture fee method and code the E/M and temporary application. Report the appropriate level office visit code (99201-99215, Office or Other Outpatient Services) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the cast application (such as 29075, Application, cast; elbow to finger [short arm]), and the x-ray (73090, Radiologic examination; forearm, 2 views).