Wiki Immobilization question

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TTcpc

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Hello,

I'm working on a fracture care research project and have questions about immobilization as it relates to global fracture care billing.

If a patient presents to the clinic in a splint or a prefab brace or boot/fracture shoe that was placed by the ER or UCC and referred over to the ortho specialist does this preclude the ortho specialist from billing fracture care global? I've confirmed that pretty much all of the ER or UCC in the area are NOT billing fracture care and are referring the patient over to the ortho specialist for all management of the fracture. The ER or UCC is merely seeing the patient and placing them in the above items for the fracture until they can get an appointment with the ortho clinic as to not risk displacement and/or monitor for growth place injury/complications.

I've seen some guidance that states no because the ortho specialist did not "change" the immobilization originally placed that you can't. Others advise to bill fracture care with modifier 55, the issue here is that the ER or UCC is not billing the initial treatment. Also, the ortho specialist may have reason for not changing a what the ER/UCC placed on the initial visit as to not disturb the fracture site and risking a displacement or to allow a little more time for swelling to subside as the patient often presents with 24-48 hrs of the fracture occurring.

Any advice/guidance for this project would be appreciated.
 
The ER or UCC will bill for the E/M and the placement of the cast, splint, boot, etc. They usually do not bill for fracture care as that would entail follow-up visits which are not done in these places of service. When the patient presents to the Ortho for their first visit, this is usually billed with a fracture care code - no charge for the first cast if done. It is not required to remove a previous cast, boot, etc. to bill for fracture care. Sometimes they are billed as an E/M with a cast separately billable if done at which time the Ortho will bill subsequent visits with an E/M. With fracture care, subsequent visits are global, however new casting can be billed separately. The only time a visit would be billed with a 55 modifier is if the global code was billed by a different provider and you are taking over the fracture care. The 55 modifier would be applied to the appropriate fracture care code and as long as the previous provider used a 54 modifier on his fracture care code, you should be reimbursed accordingly. Otherwise, if another provider billed a fracture care code without a modifier and the patient is coming to you for follow-up visits, the visits should be billed with just E/M codes and casting if done.

Hope that covers what you needed!
Jodi
 
The simple answer to your question is NO - nothing the ER does, whether it be splint/boot/brace/cast, with or without manipulation, precludes an orthopaedist from subsequently billing a Fracture Care code.

Since the Fracture Care code definitions were changed last year in CPT, ER physicians are more aggressively using Fracture Care codes with a -54 modifier, which bills more, typically, than just their ER E&M and a splint application code. If they do so, then an associated ortho provider would bill the same fracture code with a -55 modifier. However, if no transfer of care was provided, and the ortho provider is in a different practice and the patient just walks in after being treated somewhere at an ER or urgent care, there is no reason the orthopaedist would have any clue what the ER billed and so is generally not under any obligation to bill a -55 modifier.

Fracture Care without Manipulation does not require one to change a previously applied splint or boot in order to bill. There is no conflict there.

The one thing that is questionable is whether an orthopaedist can bill a new patient E&M with a -57 modifier AND a fracture care code on the same day for that injury.
 
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