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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.
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
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.