Wiki E/m with fracture care

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adunlap23

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Guidelines state that an e/m service can be billed with a fracture care code for the initial fracture treatment. Can someone clarify the term "initial fracture treatment"? Does it mean the patient's initial treatment, or the initial treatment with the physician who is performing definitive treatment?
Ex: A patient was seen in the ER for a fracture and placed in a splint. Patient was referred to ortho for definitive care. The ortho physician sees the patient in the office for the first time for the fracture in question, and performs closed reduction with casting.
Would it be appropriate for the ortho physician to bill e/m code with modifier 57, along with the proper CPT code for fx care?
 
Hello, I am not an expert. Here is my thought:
1. Initial fracture treatment ( icd-10 with a letter 'A') can by done by any provider as long as the treatment is still in place/active not just observing the healing.
2. Since ER provider is a different specialty than Ortho MD, both of them can bill e/m.
 
natashalage said:
Hello, I am not an expert. Here is my thought:
1. Initial fracture treatment ( icd-10 with a letter 'A') can by done by any provider as long as the treatment is still in place/active not just observing the healing.
2. Since ER provider is a different specialty than Ortho MD, both of them can bill e/m.
Click to expand...
Thank you. I've read through other threads that suggest we're not able to bill an e/m with fx care if the ER already billed for it...
I can't find any reputable resources to back it up either way.
 
I think we've covered this one a couple times. I know you have confusion around this issue. :) Everyone does, it is an annoying issue.
Did you search fracture care, global fracture care, closed fracture care, non op fracture care, etc. in the forums?



In your scenario above, I probably wouldn't bill the ortho E/M if billing closed reduction in this case (depending on the documentation). Let's say the patient went to ED Sunday, no reduction (? weird), splinted. Goes to ortho Monday, brings outside XR from ED is wearing splint, doc says yup fracture, closed reduced (90 day global code), casted, bills global fracture care (with no intent to take the patient to open surgery, this was the definitive treatment for the fracture). The RVUs for the global fracture care include the E/M even if a new patient in this very basic example. It's included in the global surgery fee. NOW... if there was some other circumstance which required E/M above and beyond the work included in the fracture care, then you might consider an E/M with 57. Same patient but also fell, hit head and now also has neck pain and numbness tingling in arm (or something like that). Provider would have to do more of a work up in this case in addition to the fracture.

It always depends on the documentation of the encounter. In your scenario your provider could also choose to go the itemized E/M route and bill for only E/M, casting and supplies for the entire span of treatment for the fracture and not code global fracture care at all.
 
amyjph said:
I think we've covered this one a couple times. I know you have confusion around this issue. :) Everyone does, it is an annoying issue.
Did you search fracture care, global fracture care, closed fracture care, non op fracture care, etc. in the forums?



In your scenario above, I probably wouldn't bill the ortho E/M if billing closed reduction in this case (depending on the documentation). Let's say the patient went to ED Sunday, no reduction (? weird), splinted. Goes to ortho Monday, brings outside XR from ED is wearing splint, doc says yup fracture, closed reduced (90 day global code), casted, bills global fracture care (with no intent to take the patient to open surgery, this was the definitive treatment for the fracture). The RVUs for the global fracture care include the E/M even if a new patient in this very basic example. It's included in the global surgery fee. NOW... if there was some other circumstance which required E/M above and beyond the work included in the fracture care, then you might consider an E/M with 57. Same patient but also fell, hit head and now also has neck pain and numbness tingling in arm (or something like that). Provider would have to do more of a work up in this case in addition to the fracture.

It always depends on the documentation of the encounter. In your scenario your provider could also choose to go the itemized E/M route and bill for only E/M, casting and supplies for the entire span of treatment for the fracture and not code global fracture care at all.
Click to expand...
I'm not an e/m coder, but I have a brand new physician asking me a lot of questions regarding office visits, fx care and x-rays. I have researched a ton of fracture guidelines, but I get hung up on the nuances. Each scenario is different in some way, and I'd hate to pass along the wrong advice.

My interpretation from the information I gathered was that we were supposed to report an e/m code with modifier 57, along with a fracture code for the initial visit.
The CMS global surgery guidelines state "We exclude these global surgical payment services. You may bill them separately and get paid:
● Surgeon’s initial evaluation to determine the need for major surgeries. Bill this separately using modifier –57 (Decision for Surgery). Only bill this separately for major surgical procedures."
CMS defines major surgery as having a 90-day global period. So, when a surgeon performs closed reduction without manipulation, those codes carry a 90-day global period and are considered major surgery. That's where my interpretation came from. I was just trying to determine what "initial visit" was-the ER or the Orthro office visit.

Are you saying we are to treat it more like a modifier 25 situation, and only append it if the physician is going above and beyond the e/m service? I've read threads where other coders state they always bill an e/m service with the initial fracture care. I'm not saying they're right, I'm just saying that's where the confusion comes from.
 
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