Wiki URGENT CARE BILLING Fx CARE GLOBAL & "possible" interpretation

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coding303

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I am in need of some real help here. I do not have access to Coding Clinics or any other various electronic references as I work for an independent Urgent Care facility and the only items provided to me are my CPT, ICD-9, and HCPCS text I am having trouble coding as everything that I do is questioned as I am the first certified coder they have had. Here is what I am facing today, any and all help is IMMENSELY APPRECIATED

Here is my situation: I have a provider who insists on billing fracture care. I have explained that most Urgent Care facilities do not bill global fracture care but that it is possible to do with a 54 modifier as we provide initial care. I have specifically be told to code and release charges without a modifier. "do not use modifier 54" This is an issue of much discussion between us lately and currently the 54 modifier remains.

Also, when reviewing documentation I have notes that have x-ray interpretation of "possible fracture" in the note and providers who give the diagnoses of fracture with discharge instructions that state "possible fracture". Since the physician has given the diagnoses of fracture he wants this visit to go out as a fracture with fracture care code as well. I do not feel comfortable with this as the x-ray does not show fracture and radiologist only states "possible". I understand that is the management and care that is provided but in an outpatient setting it is the presence of "possible" that leads me to believe it should not be done.

What I am hoping to have a little help with is finding information that I can present explaining that we can/cannot bill fracture care for a patient whose x-ray did not show a definitive fracture. This is my first position where coding fracture care is even a possibility so any education is helpful as well.
 
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In our clinic we will code for fractures when the treating provider diagnosis a fracture, but the radiologist does not. Reasoning is the treating provider is treating the patient. Might not be 100% correct, but that is how we diagnosis it.

As for fracture care, we used to let our urgent care provider bill fracture care with the 54 modifier, but it was a billing nightmare and we got a lot more denials than payments. So we now do not let them bill any type of fracture care. They can bill an appropriate E/M and a splint or cast if done.

I code for a group of clinics both urgent care and primary care, and let me tell you what a hassle it is when another (not our) urgent care or ED bills fracture care and than refers to our primary clinic. Our provider follows the patient through the rest of the fracture, so we bill fracture care and get denials on the primary care side because someone else is also billing fracture care.
 
Thank you aharoldsen, I believe the denials we have received for the Fx care is why he would like to bill without a modifier. This has been an ongoing discussion for the last couple weeks. I have brought up the option of only coding for the E/M, splint application, etc and I think after reading your response I will contact our billing department to find out how much time is currently being spent appealing denials and how many are then paid or written off. Thank you.
 
I used to code for an Urgent Care facility and we never billed for fracture care - it was always the appropriate LOS w/25 and the splinting code with materials. We saved the fracture care codes for when the patient was seen by the Ortho group. It doesn't not make sense to bill fracture care in the Urgent Care setting.
 
I think the question here is whether the practice then refers the patient to an ortho group.
Does the patient come back for follow-up xrays to see how the "fx" healing process is? Do they come back for removal of cast/splint?
The Urgent care practice I worked for did "definitive" care when it came to simple fractures. In other words, there was not a referral to an ortho. If the patient was told to follow-up with their primary care (if they even had one), we would code as fracture care with the modifier -54, and -57 on the E&M. We did NOT have a problem getting paid.
If they were told to return to the Urgent Care for f/u, then we coded fracture care without the modifier.

If there was ANY type of manipulation performed, then FX care was performed.

With the information you provided, I can not tell what the discharge instructions were.

As far as "possible fx", the provider is the one doing the service, and believe me, there are many times discrepancies between the radiologist and the provider. I work for the facility side ED now, and we were told to go with the providers findings.

The rule of thumb when it comes to fracture care coding is whether there is a definitive service provided. If there is not, (referral to an ortho) then code E&M and splint.
Hope this helps
 
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