Podiatry Coding & Billing Alert

Hint: Not everything is included under fracture care.

If you want to maximize your reimbursement when you bill a fracture care code (28400- 28675), you have to know what's bundled into the 90-day global period -- and more important, what's not.

Check out answers to some frequently asked questions to see whether you're making the most out of casting and strapping procedures.

Question: What is included and excluded in the global period for fracture care codes?

Answer: The Correct Coding Initiative (CCI) edits bundle the application of initial casts and strapping (29000-29750) into fracture care codes with a 90-day global period. Other procedures included in the global period are an exam (99201-99205 for new patients) and cast removal (29700-29715).

However: An x-ray (70000 series) to diagnose the fracture is not included in the global, notes Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. You should be able to code that separately.

Don't overlook: The application of a cast is included in the global, but the supplies used are separately reimbursable. Use HCPCS Level II codes, such as A4580 (Cast supplies [e.g., plaster]), to report any materials used in initial casting.

Consider Your Alternatives

You won't necessarily report a global fracture code every time your podiatrist provides a fracture care service. Some offices prefer to bill "a la carte," meaning they don't bill for fracture care and don't open a 90-day global period. Using fracture care codes is most common when the fractures don't require a manipulative reduction.

When manipulation is required, "a la carte" billing may improve the possibility for increased reimbursement. A likelihood of multiple follow-up visits also signals the value of billing services separately.

Question: How should I code for replacement casts?

Answer: If you have opened a 90-day global period for fracture care, you can still claim for the application of a replacement cast. If you want to steer clear of denials, make sure to document the medical necessity for replacement casting.

Example: An elderly patient comes in for a follow-up visit after treatment for a closed calcaneal fracture (825.0). The cast has become loose due to loss of muscle mass. The podiatrist removes the cast, x-rays the area, and applies a new cast. You would code for 29405 (Application of short leg cast [below knee to toes]) along with the appropriate HCPCS Level II codes for materials. The notes should document that the cast was not providing full protection due to loss of patient's muscle mass, and replacement was therefore medically necessary.

Generally, E/M codes for replacement casting are not applicable when the visit occurs within the 90-day global period, but there can be exceptions. One example when an E/M code may be justifiable is if the reason for a cast change is due to injury or an unusual circumstance, experts say.

Appending modifier 25 to the E/M code can indicate to a payer that the podiatrist performed a significant, separately identifiable service above and beyond the usual service provided.

Some payers require modifier 58 (Staged or related procedure by the same physician during the post-operative period) to indicate that the cast is part of the same treatment plan, but that guideline can vary. "Medicare requires the modifier," says Ruby O'Brochta Woodward, BSN, ACS-OR, compliance and research specialist with Twin Cities Orthopedics in St. Louis Park, Minn. "I have successfully billed this to the private health plans without the modifier without a problem."

Tip: You can also use E/M codes when repairing, instead of replacing a cast. Don't forget your HCPCS Level II codes to bill for any supplies needed in the repair, such as A4580 for repair of plaster casts or A4590 (Special casting material [e.g., fiberglass]) for repair of lightweight casts. Caution: When billing Medicare for cast supplies, be sure to use appropriate Q codes instead of HCPCS.

Reference These Rules for Referrals

Question: How should I code for casting when an attending emergency department (ED) physician stabilized a patient's fracture?

Answer: If the ED physician performs temporary stabilization of the injury, the podiatrist can still choose whether to code for global fracture care or claim services separately, including E/M for a new patient (99201-99205), casting, and materials. Beware: EDs may sometimes erroneously claim reimbursement using the global fracture care codes. Make sure your documentation indicates initial definitive treatment of the injury, so you can defend your right to global billing.

Exception: If more than one week has elapsed between the ED visit and the patient's arrival in your office, the opportunity to claim global fracture care has likely elapsed. When healing has already begun, you can use the appropriate individual codes for follow-up care, such as E/M, x-ray, and casting. The other option is to use a global fracture code appended with modifier 55 (Postoperative management only) to indicate that the podiatrist only provided postoperative care.