Podiatry Coding & Billing Alert

Remember: E/M codes aren’t automatically allowable.

When a patient presents with a fractured ankle, your podiatrist is likely to apply a cast or splint. But with dozens of CPT^® codes describing fracture care, casting, and splinting, it can be challenging to select the right code.

To get a firmer grasp on how to differentiate ankle fracture care claims from casting claims, check out this quick primer, along with some expert analysis.

What’s Involved in Fracture Care?

Fracture care is considered “restorative treatment” that covers all of the care a physician provides to address a fracture from beginning to end. The majority of fracture care codes have 90-day global periods, meaning that almost all care provided to address the fracture — starting on the first day of treatment and continuing for another 90 days — is included in the fracture care code.

You’ll find multiple options for coding fractures, and the descriptions for these were revised in the introduction to the musculoskeletal section of CPT^® 2022, as follows:

• Manipulation: Reduction by manually applying force or traction to achieve satisfactory alignment of the fracture or dislocation.
• Traction: Applying a distraction or traction force to the affected limb.
• Closed treatment: The provider reduces the fracture using external manipulation and does not surgically open the injury.
• Percutaneous skeletal fixation: Treatment that is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins, screws) is placed across the fracture site.
• Open treatment: The provider surgically opens the site to expose the fracture for treatment.
• External fixation: Pins and/or wires that penetrate the bone(s) and intercon­nection devices are used for fracture/dislocation treatment.

How Do You Select an Ankle Fracture Care Code?

Your first step in reporting a code for ankle fracture care is to pinpoint the anatomic region that the podiatrist addressed. Check the documentation for specifics, since you can’t simply find “ankle fracture” in CPT^®. Instead, you must know the specifics of whether the fracture was bimalleolar, trimalleolar, lateral malleolus, or another type.

“A bimalleolar ankle fracture will involve two bones: the medial, distal, end of the tibia — or medial malleolus; and the distal, outside, end of the fibula — or lateral malleolus,” according to Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. Additionally, a bimalleolar fracture can also be a break of the medial and posterior malleoli or the lateral and posterior malleoli. Once you pin down the location, you’ll find the fracture care type using the criteria above.

For bimalleolar fracture treatment, you should report the following codes:

• For closed treatment, report 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation) or 27810 (... with manipulation)
• For open treatment, report 27814 (Open treatment of bimalleolar ankle fracture, (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed)

For medial malleolus fracture treatment, where the patient fractures the inner side of the ankle at the end of the tibia, you should report the following, says Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan:

• For closed treatment, report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 (... with manipulation, with or without skin or skeletal traction)
• For open treatment, report 27766 (Open treatment of medial malleolus fracture, includes internal fixation, when performed)

For posterior malleolus fracture treatment, where the patient has a fracture at the distal posterior aspect of the tibia, you should report the following:

• For closed treatment, report either 27767 (Closed treatment of posterior malleolus fracture; without manipulation) or 27768 (... with manipulation)
• For open treatment, report 27769 (Open treatment of posterior malleolus fracture, includes internal fixation, when performed)

And for trimalleolar fracture treatment, where the fracture involves the medial malleolus, the lateral malleolus, and the posterior malleolus, you should report the following:

• For closed treatment, report 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) or 27818 (... with manipulation)
• For open treatment, use 27822 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 (... with fixation of posterior lip)

Reporting an E/M With Fracture Care

You can only report a separate evaluation and management (E/M) service with fracture care if you can prove that the E/M service was significant and separate from the fracture care. For instance, suppose a new patient reports to the podiatrist complaining of ankle pain. After taking a history and performing an exam, the podiatrist diagnoses a fractured ankle and performs closed manipulation. In this case, you can report both the fracture care and the E/M code.

You’ll append one of the following modifiers to the E/M code to denote that it was significant and separate from the fracture care:

Modifier 25: (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) if the fracture care code has a 0- or 10-day global period.

Modifier 57: (Decision for surgery) if the fracture care code has a 90-day global period.

In some cases, however, you won’t be able to report a separate E/M code with your fracture care code. For instance, suppose an established patient reports to the podiatrist for scheduled repair of the left great toe. Notes indicate that the podiatrist discussed the treatment and course of recovery before performing the repair. On this claim, the E/M is part of the work units for the toe repair, so you would not separately report an E/M code with the repair.

How to Bill for Casting

Although podiatrists frequently report global fracture codes for fracture care, that won’t be the case every time your podiatrist addresses a fracture. In some instances, you’ll bill “a la carte,” meaning you don’t bill for fracture care and don’t open a 90-day global period.

CPT^® reports, “If cast application or strapping is provided as an initial service (e.g., casting of a sprained ankle or knee) in which no other procedure or treatment (e.g., surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code in addition to an evaluation and management code as appropriate.”

Therefore, if the podiatrist applies a cast, you’ll report the appropriate casting code (such as 29405, Application of short leg cast (below knee to toes)). Although the National Correct Coding Initiative (NCCI) bundles the E/M codes into the casting codes, you can report them together with modifier 25 as long as you document and perform a significant and separately identifiable E/M code.

Remember: You cannot report a separate casting code for the initial cast application when you report fracture care, CPT^® notes. In addition, NCCI edits bundle the application of initial casts and strapping (29000-29750) into fracture care codes. However, you can (and should) report the actual casting supplies along with the fracture care code. For instance, a plaster short leg cast would be coded with Q4037 (Cast supplies, short leg cast, adult (11 years +), plaster).

Supplies: Don’t forget to report the appropriate casting supply codes along with your casting procedure code and (when applicable) your E/M code.

Ultimately, the choice of whether to report fracture care or casting will come down to what the provider documents. If the podiatrist performs and documents fracture care (such as a fracture reduction or manipulation), you’ll typically report a fracture care code. And if they document only casting, you’ll submit a casting code instead.