Wiki Fracture care debate

[Queizati]

We have a physician at our practice who is very eager to bill closed fracture treatments CPT codes- from scenarios ranging from a fracture that has not been confirmed on imaging to fractures that have been confirmed on imaging as healed but with malunion. For the latter scenario, I explained to the physician that the x-ray report dictates the distal radius fracture has healed, to which she then said there is malunion of the fracture and complications such as contracture. The patient was given a day and night splint and referred to a hand surgeon. In my opinion, as the radiographs dictate the fracture has healed and the complications resulting from the fracture are being treated, billing for closed treatment of a fracture in this scenario would be inappropriate.

I've searched high and low for any information regarding this scenario and have come up with nothing. The CPT manual Muskoskeletal guidelines do not even cover this area for me to be able to bring back to support my case. Does anyone have any input on this?

 

[amyjph]

The good old fracture care debate...
This was related to DME but you can read the links for more info on fracture care: https://www.aapc.com/discuss/threads/2022-cpt-fracture-tx-update.185046/?view=date#post-506481

One thing I noticed in your example is the part about the provider wanting to charge for fracture care but then referring the patient to a hand surgeon. If you read the CPT musculoskeletal system intro guidelines "If the person providing the intial treatment will not be providing the subsequent treatment, modifier 54 should be appended to the fracture/dislocation treatment codes. If treatment of a fracture as defined above is not performed, report an evaluation and management code." So, you need to read through that whole section because it addresses some of this. Also: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53322

There is always the additional debate about the fact that closed tx CPT, with few 0 day exceptions, puts the patient in a 90 global. Patients often do not understand this if it is not explained to them and are upset later. Also, if a provider charges the global full code with no modifier 54 and the patient is referred elsewhere the provider is incorrectly getting full payment in that global fee for the "post operative" (follow up) care. You also create additional issues if the provider also wants to report an E/M with a 25 modifier AND the fracture care.

There are CPT Assistant articles on some of the closed tx codes I think, you could check there for help.
The NCCI manual has some references: https://www.cms.gov/sites/default/files/2021-12/Chapter4_2022_CMP_Final_1.1.2022.pdf

I have never seen a provider charge for closed treatment for a malunion or nonunion... In my opinion that's not what the closed fracture codes are for and would probably create a medial records request, denial and/or audit situation if it was done. it just seems really wrong. You would be using the ICD-10 for malunion/nonuion and that just doesn't match up with restorative fracture care for a new traumatic fracture. Also if you read through the links, it states providing a splint or cast solely for patient comfort (and not restorative treatment) is not closed treatment. Most times, they are going to take the patient for treatment of the malunion or nonunion with open surgery anyway depending on severity.

(2022) Billing Guidelins For Closed Treatments Of Fractures

By Mary LeGrand, RN, MA, CCS-P, CPC; Margaret Maley, BSN, MS; Robert H. Haralson III, MD, MBA; M. Bradford Henley, MD, MBA; Matthew Twetten, MA Fracture care coding guidelines CMS is controversial; this article provides suggestions on how to code for this form of treatment. Closed treatments are...

www.codingahead.com

Submit Form

I'm not saying closed treatment should not or cannot be charged, there are plenty of appropriate instances where it can be done. It seems, especially for the second scenario you describe, it would be better to bill the E&M, and any separately reportable X-Rays, etc. for a single visit where the patient is being referred elsewhere.

 

[hannahevola]

I've found this article to be extremely helpful when coding closed treatment without manipulation. It advises what documentation requirements are necessary in order to report the fracture care codes.

Don’t Break Your Fracture Care Revenue Cycle

Coding thoughts for closed treatment of fractures without manipulation Coding closed treatment of fractures without manipulation can be a challenge. To

www.aapc.com