Primary Care Coding Alert

Does fracture care have a time limit? The answer may surprise you

If your family physician sets fractures in the office but you-re still puzzled by fracture care coding rules, review the following three FAQs to clear up the confusion.

Question 1: A patient presents with arm pain, and the physician diagnoses her as having a radius fracture. The patient says she doesn't want to have it casted without her daughter there because she is afraid she won't be able to drive home afterward. The patient doesn't return to our practice for another week. Can we still bill the fracture care code, or is it too late at that point?

Answer: Regardless of the time that elapsed between the patient's initial visit and the time the physician treated the fracture, only the physician can determine whether his treatment meets the CPT definition of fracture care. Fractures heal at different rates based on a number of factors, so the physician might think the fracture has healed enough that the patient requires little or no additional treatment. In that case, you should simply report the appropriate E/M code.

If, however, the physician sees the patient the following week and performs fracture care, -by all means you can report the fracture care code,- says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, owner and president of Healthcare Consulting & Coding Education LLC in Boardman, Ohio.

If the physician chooses to bill a fracture care code, you should report an E/M code for the first visit and the appropriate fracture care code when the patient returns, Vogelberger says.
   
For example: The FP diagnoses a patient with an ulnar shaft fracture and splints the fracture so the patient can return with her daughter. The patient comes to your office a week later, and the physician performs closed treatment with manipulation.

You should report 25535 (Closed treatment of ulnar shaft fracture; with manipulation).

Keep in mind: There is no -standard- on fracture care time limits. In fact, some patients don't even come into the office for a fracture for several days because they are trying to live with it, thinking it is nothing serious.

Let Physician Choose Fracture Care Code Rules

Question 2: A patient presented with a hairline fracture, but the physician didn't have to perform manipulation or casting because the fracture was so minor. Should we report fracture care, or should we just report an E/M code and x-ray code?

Answer: -It's up to the physician to bill this as fracture care or a la carte,- says Denise Paige, CPC, secretary of the American Academy of Professional Coders- Long Beach chapter. 

-Personally, in my practice, unless the fracture requires a manipulative reduction, we choose to bill for the service separately, meaning no fracture care,- Paige says. -If you bill a fracture care code, you open a 90-day global period, and any subsequent office exams are not billable. But in this scenario, you can go either way.-

Reminder: Your patient may not understand that the fracture codes represent a -surgery,- even though the physician never made an incision. -It may help to explain your office policy when choosing to bill using the fracture care codes,- Paige says.

Modifiers Can Separate Sites

Question 3: If a patient has two metacarpal fractures and a wrist fracture of the same hand, how should we modify these procedures for the maximum amount of reimbursement?

Answer: You should code the wrist fracture first because it represents the physician's major service. For example, you might report 25680 (Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation). And you should add the appropriate site modifier (LT for the left side and RT for the right side).

List the metacarpal fracture codes (such as 26600, Closed treatment of metacarpal fracture, single; without manipulation, each bone) on separate lines, with the appropriate modifiers.

And you should append modifier 51 (Multiple procedures) to the metacarpal fracture and modifier 59 (Distinct procedural service) to the second metacarpal fracture so the insurer won't deny it as a duplicate charge. Therefore, your claim might appear as follows:

- 25680-LT

- 26600-51-LT

- 26600-59-LT.