Wiki Fracture Care Coding

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KoBee

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Hello -

Noticed our urgent care provider and orthopedic provider try to bill the same fracture manipulation/non-manipulation code. But we know only one should be able to bill it.

If a patient is seen at our urgent care and applies a splint and wants the patient to follow up with orthopedic. For urgent care visit, should we be billing the fracture care code as well with modifier 57 on E/M or should it just be E/M and allow the orthopedic to bill for fracture care code to start global?


Help is much appreciated it, gets a bit confusing. Thank you
 
This is where a 54/55 modifier would come into play. You would probably need the 57 also. I would argue though, that the urgent care provider should just bill the E/M, casting or splinting and supplies if they do not intend to follow the patient for the global of the fracture care and are stablizing for the ortho to f/u. It comes down to the definition of "restorative care". Are they going to stabilize or manipulate the fracture, apply splint/case, AND follow the patient through the healing and recovery phase or not? Otherwise, if the urgent care provider wants to bill non-op fracture care they would have to append a 54 modifier every time (if billing the manipulation or non-manipulation CPT w/ a global) because they are not going to do the post op care if they intend to refer the patient to an ortho surgeon. This would then require the ortho surgeon (if they do the exact same thing and don't take the patient to surgery) to append a 55 modifier to the same CPT as they will provide the post op care. As a prior manager of an ortho coding team, I can tell you this is really frustrating because it requires that you know the urgent care or other provider billed the same CPT, correctly, and appended a 54. We used to have to call other providers to see how they billed which is a nightmare.

NCCI has some guidance: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-4.pdf

Some of these have older dates (keep in mind) however, have good info:
See here under fracture care: https://www.aaos.org/quality/coding-and-reimbursement/aaos_now_article_archives/
 
I have a situation in which a closed reduction under anesthesia was performed by both urgent care and ortho providers. The urgent care provider performed moderate sedation and my ortho surgeon did the fx reduction. My claim was denied because the urgent care provider billed the same fx code and added mod -54 (surgical care only). I did some research and this is what I found. The provider who performs moderate sedation should only bill sedation moderation observation in category 99xxx, and sedation drug injection (if any). The ortho provider will then bill fx reduction code. I tried to coordinate with the urgent care billing to revise their claim. Still waiting to hear back from them.
 
Mluong said:
I have a situation in which a closed reduction under anesthesia was performed by both urgent care and ortho providers. The urgent care provider performed moderate sedation and my ortho surgeon did the fx reduction. My claim was denied because the urgent care provider billed the same fx code and added mod -54 (surgical care only). I did some research and this is what I found. The provider who performs moderate sedation should only bill sedation moderation observation in category 99xxx, and sedation drug injection (if any). The ortho provider will then bill fx reduction code. I tried to coordinate with the urgent care billing to revise their claim. Still waiting to hear back from them.
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Why did the fracture require another closed reduction if the urgent care provider had already performed? Did the fracture shift? What were the codes billed?
I would want to see more information and the documentation of this.
Do the providers work under the same group/entity?
This scenario described doesn't add up.
 
Mluong said:
I have a situation in which a closed reduction under anesthesia was performed by both urgent care and ortho providers. The urgent care provider performed moderate sedation and my ortho surgeon did the fx reduction. My claim was denied because the urgent care provider billed the same fx code and added mod -54 (surgical care only). I did some research and this is what I found. The provider who performs moderate sedation should only bill sedation moderation observation in category 99xxx, and sedation drug injection (if any). The ortho provider will then bill fx reduction code. I tried to coordinate with the urgent care billing to revise their claim. Still waiting to hear back from them.
Click to expand...
Each physician should report the service(s) personally provided. If the urgent care physician was providing moderate sedation for the fracture reduction, that is not fracture care. As you note, the appropriate moderate sedation code should be reported (provided all requirement are met). If for some reason, a reduction required a co-surgeon or assistant surgeon, then both surgeons would bill for the fracture care with the appropriate modifiers. Hope that helps. Cindy
 
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