Based on my personal experience as an Orthopedic Surgeon, and in working with the Billing and Coding Department of our Multi-specialty Clinic, my Coders advised me several years ago that many payers at that time did not even recognize or pay for Fracture Care Codes for "Closed Treatment of ..... fracture without manipulation." As such, they recommended charging the appropriate E&M code for the level of service. Of course, a
diagnosis code would have to be used and accurate. In these scenarios, the application of a Cast, Splint, or Off the Shelf Prefabricated Splint/Device could be charged for with Modifier 25 for materials and application. We had separate charges for application and materials, again with the appropriate Modifier. This would apply to an Initial Evaluation by the Surgeon when the patient had not been seen or treated elsewhere (ER, Walk-in Clinic, etc.). If the patient had prior E&M elsewhere and came in with a Cast, Splint, or Off the Shelf Device in place, then you wouldn't charge for materials and application if there was no change in the treatment plan. If the Surgeon on first evaluation decided to use a different method of external immobilization, i.e. a change of treatment plan, and applied something else, then the materials and application could be charged for.
By using a Fracture Treatment Code for these cases, for which you may or may not be compensated, you are tied to a Global Fee time frame, pretty much the 90 day time period. With that, you can only charge for follow up Xray studies and interpretation, and for Cast, Splint, or Off the Shelf Devices when a change is warranted due to wear or "no longer fits" well enough to provide the required immobilization support, etc. The subsequent office visits are not charged for. Furthermore, these Fracture Treatment Codes generally include the application and materials of the Cast, Splint, Device used, so you may not be successful in getting paid for them when it is the Initial Evaluation and Treatment.
My "advisors" told me to use the E&M Codes, etc. as above when these occasions occurred as we were more likely to get paid something for visits, casts etc., and X-ray studies than by using Fracture Codes. You would have to know what the particular patient's payer is going to recognize and cover. The patients are not necessarily be happy with the multiple office charges for each visit, but you have to go the route that is going to get you paid.
Respectfully submitted, Alan Pechacek, M.D.
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