Wiki Fracture Care

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KoBee

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Am I the only one who gets a bit confused when to code the fracture care using modifier 25 or 57.

If a patient is seen in our urgent care and they have a fracture and sling applied only, follow up with our internal orthopedic. We only code E/M
Patient follows up with ortho, fracture with no manipulation, splint applied. We code E/M and fracture care code but when are you to use modifier 25 or 57 with fracture care code?

Majority of fracture care codes with or without manipulation are 90 day global.

Any source or help is appreciated. Thank you
 
Can you clarify your question please? Your urgent care clinic is billing fracture, but who is doing the follow up? A doc in your clinic or another doc in a different practice?
 
Aside from the question on the clinic or practice and fracture care; this is a separate question about the proper use of modifiers 25 and 57. It can be separated from the fracture care question.
Read the CPT definitions of modifier 25 and modifier 57.
Also see here:

Modifier 25 fact sheet

www.novitas-solutions.com www.novitas-solutions.com

Modifier 57 Fact Sheet

www.novitas-solutions.com www.novitas-solutions.com
Search within this manual and see here (G. Fractures, Dislocations, and Casting/Splinting/Strapping): https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-4.pdf
ACEP has info: https://www.acep.org/administration...thopedic-fracture--dislocation-management-faq
Some helpful info here: https://www.doctorsmanagement.com/blog/understanding-office-based-fracture-care/
Search in the forums for the words: fracture care, non-op fracture care, global fracture care, closed fracture care, etc. There are tons of posts about this topic.

Depending on the clinic/provider/internal and external, etc. modifiers 54 and 55 could come into play.
Example: Patient on vacation in Aspen, falls skiing and fractures distal radius, ortho surgeon there sees patient and performs ORIF but will do no post op visits in global. Patient goes back home and all follow up is done by the home orthopedic surgeon who will do all post op visits. 54/55 scenario.

In your question above, it depends on the date of service among many other things.
Day one: Patient goes to your urgent care, sees PA, fracture, sling, no manipulative treatment. E/M charged and sling.
If same patient goes to your internal ortho the next calendar day and ortho is charging fracture care (25500 for example w/ 90 day global) and the documentation supports both an E/M and the 25500 (questionable), you would require both modifiers IF the providers are under the same EIN/group/NPI.
Urgent Care: 9920_ -57 (assuming new patient). Have to use 57 if a 90 day global is going to be charged in the same group the day before or day of.
Ortho Doc: 9921_ - 57, 25500 (if same group possibly could be another new patient e/m depending on subspecialty and payer). Might need a 25 too depending on payer.
If the same thing happened as above but the patient did not go to ortho until two calendar days later, the urgent care doc would not append a 57. The ortho doc would do the same as above.
Many times it is not appropriate to code a separate E/M with modifier 25 for closed treatment billing because those codes live in the surgical section and include pre, intra and post-service work in the payment. Depends on the documentation.
There are A LOT of ifs in this. The scenario changes if the providers are two totally separate groups.
Keep in mind providers can always go the itemized route and do E/M and casting (if needed) at each visit instead of the global fracture care route.

Sorry long-winded response but this topic drives me nuts and is probably in the top 5 most asked questions by orthopedics.

Helpful if you want to take course: https://educate.kzanow.com/products/fracture-care-step-by-step
 
KoBee said:
Am I the only one who gets a bit confused when to code the fracture care using modifier 25 or 57.

If a patient is seen in our urgent care and they have a fracture and sling applied only, follow up with our internal orthopedic. We only code E/M
Patient follows up with ortho, fracture with no manipulation, splint applied. We code E/M and fracture care code but when are you to use modifier 25 or 57 with fracture care code?

Majority of fracture care codes with or without manipulation are 90 day global.

Any source or help is appreciated. Thank you
Click to expand...
I hope this helps. I work for an orthopaedic practice. If the DR wants me to bill for fracture care, I will bill out an E/M along with a fracture care code. On the E/M we always do a MOD 57. We never once used a 25. It is always a 57.
 
The Urgent Care should code E&M and then Fracture Care with a 57 modifier AND a 54 modifier because they clearly are not going to provide the post-evaluation care.

The orthopaedist could code Fracture Care with a -55 modifier, OR E&M only, but unless he or she changes from Without Manipulation to With Manipulation, he's already within the global period established by the Urgent Care for the same "procedure" and really has no right to charge both E&M AND Fracture Care.

In most cases, the orthopaedist will make out better by skipping Fracture Care and just coding E&M.
The 25 modifier is not appropriate in this setting.
 
nraizman@gmail.com said:
The Urgent Care should code E&M and then Fracture Care with a 57 modifier AND a 54 modifier because they clearly are not going to provide the post-evaluation care.

The orthopaedist could code Fracture Care with a -55 modifier, OR E&M only, but unless he or she changes from Without Manipulation to With Manipulation, he's already within the global period established by the Urgent Care for the same "procedure" and really has no right to charge both E&M AND Fracture Care.

In most cases, the orthopaedist will make out better by skipping Fracture Care and just coding E&M.
The 25 modifier is not appropriate in this setting.
Click to expand...
So we would we give the urgent care credit for fracture care even if they only applied a sling? I thought if there is really no surgical intervention it would not be appropriate to give urgent care fracture care with mod 54.
 
KoBee said:
So we would we give the urgent care credit for fracture care even if they only applied a sling? I thought if there is really no surgical intervention it would not be appropriate to give urgent care fracture care with mod 54.
Click to expand...
The CPT definitions for fracture care changed in 2022, despite vehement opposition, to make the barriers for ER providers coding Fracture Care much lower.

Any ED provider who “manages” a fracture can bill the fracture code, though they should always use the 54 modifier, as they know they are not going to manage the patient through the global period. Throwing a sling or splint on is technically sufficient, however sketchy it is from an Orthopaedic perspective.
 
KoBee said:
So we would we give the urgent care credit for fracture care even if they only applied a sling? I thought if there is really no surgical intervention it would not be appropriate to give urgent care fracture care with mod 54.
Click to expand...
Does your practice own both the urgent care and the orthopedic office? This complicates matters. Is it a "walk-in" no appointment necessary type urgent ortho within your main orthopedic office? Do they have the same NPI/Tax ID? This would matter. If you are talking about an external urgent care not affiliated with your practice, they can do whatever they want. They might bill a closed treatment of fracture with or without manipulation depending on what was done, OR they might bill an E/M with casting and supplies. You are confusing "no surgical intervention" with the ability of a provider to choose to bill closed fracture treatment with or without manipulation.

The urgent care provider technically "could" charge the closed treatment of fracture without manipulation for application of a sling. That is the definition of closed treatment without manipulation, they apply a sling, cast or splint. If they do it, they have to append a 54 because they will not be providing the global post op care. Getting them to append it is another story.

If you are coding for the urgent care and the orthopedic provider which are under the same Tax ID/NPI umbrella, it would be better to charge the E/M, cast/splint and/or supplies for the urgent care and then when the patient goes to the orthopedic provider, that provider can decide whether to go the fracture care route or the E/M route, or the patient may end up needing scope or open surgery so you wouldn't do the closed treatment route because they are being taken for surgery. I think that is what your first and main question was. The ortho provider is the one making the definitive care decision.

I would probably be inclined to code the WITH manipulation codes by the urgent care if they manipulated it.

At the end of the day the practice/providers would have to decide which route they want to take, it is always a choice between the "surgical section" CPT codes for closed fracture treatment with or without manipulation versus coding the E/M with the casting/splinting and supplies. It also depends on how the practice is set up and if you are coding for both urgent and ortho and they live under the same EIN.

The modifier answer is that you would need a 57 if you are coding the closed treatment codes with a 90 day global. You would need a 25 if the closed treatment has a 0 or 10 day global.
 
amyjph said:
Does your practice own both the urgent care and the orthopedic office? This complicates matters. Is it a "walk-in" no appointment necessary type urgent ortho within your main orthopedic office? Do they have the same NPI/Tax ID? This would matter. If you are talking about an external urgent care not affiliated with your practice, they can do whatever they want. They might bill a closed treatment of fracture with or without manipulation depending on what was done, OR they might bill an E/M with casting and supplies. You are confusing "no surgical intervention" with the ability of a provider to choose to bill closed fracture treatment with or without manipulation.

The urgent care provider technically "could" charge the closed treatment of fracture without manipulation for application of a sling. That is the definition of closed treatment without manipulation, they apply a sling, cast or splint. If they do it, they have to append a 54 because they will not be providing the global post op care. Getting them to append it is another story.

If you are coding for the urgent care and the orthopedic provider which are under the same Tax ID/NPI umbrella, it would be better to charge the E/M, cast/splint and/or supplies for the urgent care and then when the patient goes to the orthopedic provider, that provider can decide whether to go the fracture care route or the E/M route, or the patient may end up needing scope or open surgery so you wouldn't do the closed treatment route because they are being taken for surgery. I think that is what your first and main question was. The ortho provider is the one making the definitive care decision.

I would probably be inclined to code the WITH manipulation codes by the urgent care if they manipulated it.

At the end of the day the practice/providers would have to decide which route they want to take, it is always a choice between the "surgical section" CPT codes for closed fracture treatment with or without manipulation versus coding the E/M with the casting/splinting and supplies. It also depends on how the practice is set up and if you are coding for both urgent and ortho and they live under the same EIN.

The modifier answer is that you would need a 57 if you are coding the closed treatment codes with a 90 day global. You would need a 25 if the closed treatment has a 0 or 10 day global.
Click to expand...
I see.

in our case, yes our practice own both the urgent care and the orthopedic office. Do they have the same NPI/Tax ID.

Patient seen at our urgent care , xray, advil, referral to ortho.

Patient comes in 5 days later with ortho, Right distal radius fracture with manipulation, short arm cast applied, return in 6wks

Urgent Care
E/M

Ortho
EM-25 (provider wants to bill with modifier 25)
25605



Would this be correct? I wanted to change the modifier to 57.
 
KoBee said:
I see.

in our case, yes our practice own both the urgent care and the orthopedic office. Do they have the same NPI/Tax ID.

Patient seen at our urgent care , xray, advil, referral to ortho.

Patient comes in 5 days later with ortho, Right distal radius fracture with manipulation, short arm cast applied, return in 6wks

Urgent Care
E/M

Ortho
EM-25 (provider wants to bill with modifier 25)
25605



Would this be correct? I wanted to change the modifier to 57.
Click to expand...
Modifier 25 would not be correct in this example because the 25605 has a 90 day global.
The patient waited 5 days to get in to the ortho? The urgent care didn't splint or anything?
In your example, without seeing any notes, I would probably do it the way you have with the correction to 57 from 25. However, I would really want to see the specific documentation of the E/M service by the ortho for second visit.
My opinion is these scenarios can be very different depending on the documentation.

The urgent care can certainly just do the E/M. The ortho provider could also have chosen to do the E/M route and bill the casting and supplies with it. OR, the ortho can do it the way you show with the global fracture care code.
 
amyjph said:
Modifier 25 would not be correct in this example because the 25605 has a 90 day global.
The patient waited 5 days to get in to the ortho? The urgent care didn't splint or anything?
In your example, without seeing any notes, I would probably do it the way you have with the correction to 57 from 25. However, I would really want to see the specific documentation of the E/M service by the ortho for second visit.
My opinion is these scenarios can be very different depending on the documentation.

The urgent care can certainly just do the E/M. The ortho provider could also have chosen to do the E/M route and bill the casting and supplies with it. OR, the ortho can do it the way you show with the global fracture care code.
Click to expand...
I think where I am confused is with the ortho. Do they have the option to do global or itemized? if so then modifier 25 would be correct. I guess as a coder, should i be looking at the global of the procedure which is 90 day so on the E/M i would use 57 to make a decision on what modifier?? If we use modifier 25 then payer can come back and say any follow up is part of the global, right?

Here is another example:

Patient when to our Urgent care on 11/3/24
E/M - 25
29515 Splint application
crutches given
Referral to ortho

Patient came to see our ortho on 11/12/24
E/M-25 (provider wants to bill with modifier 25)
27788 - manipulation


Ortho visit note:
Chief Complaint: Right distal fibula fracture
Date of Injury: 11/2/24
History of Present Illness: This is a 58 y.o.female unemployed who present with a Right distal fibula fracture sustained when she was walking and trip over an object at her trailer and twisted her ankle.

1731600618077.png
 
The ortho has the option to choose one or the other method. Either itemized or global. If they choose itemized, no global fracture care (with or w/o manipulation code) is used. Therefore, a 57 is out of play. If they are billing for casting with the E/M the 25 comes into play. If they want to bill the global, and the cpt (with or w/o manipulation) has a 90 day global, the 57 comes into play. Does that make sense? The 25 or 57 is dependent on what is being billed along with the E/M. A 0-10 day global or a 90 day global.

In your example, the ortho is confusing you by appending a 25 to the E/M with 27788. It would be a 57 because 27788 has a 90 day global. (provided all the documentation supports, etc. etc.)
 
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