Podiatry Coding & Billing Alert

Beware: E/M codes are not always billable.

When a patient comes in with a broken ankle, your podiatrist will probably use a cast or splint. However, choosing the correct code can be difficult due to the multitude of CPT® codes that describe fracture treatment, casting, and splinting.

For a better understanding of how to distinguish between codes for ankle fracture care and casting, consider this brief guide, complemented by some professional insight.

What Does Fracture Care Entail?

Fracture care is viewed as a comprehensive treatment that encompasses all the services a doctor offers to manage a fracture from start to finish. Most fracture care codes come with 90-day global periods, implying that nearly all the care given to treat the fracture — beginning from the first day of treatment and extending for an additional 90 days — is incorporated in the fracture care code.

You’ll find multiple options for coding fractures, and the descriptions for these in the introduction to the musculoskeletal section of CPT^® 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 (e.g., 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. According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, CEO of Healthcare Inspired LLC, in Bella Vista, Arkansas, “Whether the podiatrist treats a bimalleolar, medial, posterior, or trimalleolar fracture, each treatment approach has specific codes. Identifying the fracture type and treatment method — whether closed, open, or requiring manipulation — is key to ensuring correct coding and reimbursement. Proper documentation and a clear understanding of the fracture’s location and severity are essential for selecting the right CPT^® codes.”

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

• 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)
• 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 one of the following:

• Closed treatment, report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 (... with manipulation, with or without skin or skeletal traction)
• 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 one of the following:

• Closed treatment, report either 27767 (Closed treatment of posterior malleolus fracture; without manipulation) or 27768 (... with manipulation)
• 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 one of the following:

• Closed treatment, report 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) or 27818 (... with manipulation)
• 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)

What About Reporting an E/M With Fracture Care?

A distinct evaluation and management (E/M) service can only be reported alongside fracture care if it can be demonstrated that the E/M service was substantial and independent from the fracture care. For example, if a new patient visits the foot doctor with complaints of ankle discomfort, and after conducting a history and examination, the doctor identifies a broken ankle and carries out closed manipulation, then both the fracture care and the E/M code can be reported.

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 certain situations, you may not be able to claim a separate E/M code with your fracture care code. According to McNamara, for example, “if a patient comes to the podiatrist with a trimalleolar ankle fracture, after examining the injury, the podiatrist discusses treatment options and decides surgery is necessary.”

In this case, the initial E/M service that led to the decision for surgery can be reported separately if it occurs during a previous encounter. However, during the preoperative visit after the decision for surgery is made, the podiatrist reviews the procedure, discusses the surgical plan, and goes over postoperative care. Under the global surgical package rules, this preoperative visit is included in the surgical code (such as code 27822).

“Because the decision for surgery was already made, and this visit is related to the preparation for the surgery, you cannot report a separate E/M code. The work done during the pre-op visit is already bundled into the global period of the surgical procedure,” explains McNamara.

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.”

If the podiatrist applies a cast, report the suitable casting code, like 29405 (Application of short leg cast (below knee to toes)), for a short leg cast. Despite the National Correct Coding Initiative (NCCI) bundling E/M codes into casting codes, they can be reported together with modifier 25, provided a significant and separately identifiable E/M code is documented and performed.

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.

The decision to report fracture care or casting depends on the provider’s documentation. If the practitioner performs and records fracture care like reduction or manipulation, a fracture care code is reported. If only casting is documented, a casting code is submitted.