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Reviewing documentation and selecting codes for fracture care is not always as straightforward as it may seem. Often when I am working with clients, I find that information related to office-based fracture care is at times omitted and left up to assumption mostly based on the diagnosis code(s) the patient has. It is important for us to understand not only the CPT code descriptions but also what is expected from a documentation perspective to back up medical necessity and the care that is being rendered. 

To code for fracture care, we must analyze the documentation to determine what the definitive treatment plan is going to be. The documentation must show whether the treatment will include operative vs. non-operative methods before we move forward with billing office-based non-surgical fracture care. Keep in mind that at times further diagnostic testing may be required for the provider to determine if operative fracture care is indicated. In that scenario, the coding/billing process should not automatically include billing out a non-surgical fracture care code at the first visit. 

Four Types of Fracture Care Treatments

There are typically four different types of treatment that we have to choose from within the CPT index:

  • Closed treatment without manipulation (non-surgical)
  • Closed treatment with manipulation (non-surgical)
  • Open reduction with internal fixation (ORIF) 
  • Percutaneous fixation

Closed treatment without manipulation is characteristically the most understood type of fracture care. The question we come against here is, what establishes the fact that the treatment occurred? This is when it becomes vital that we understand what is included from a CPT perspective so that we can ensure that the information is represented in the documentation. 

Treatment without manipulation includes the main goal of stabilization to assist with the healing of the fracture site and at times for joint immobilization. The way in which this is done is going to depend on the anatomic location of the fracture and the treatment decisions made by the provider. 

Immobilization of the area can be done with different materials including customized or prefabricated casts, braces, splints, boots, etc.  If the casting or splinting is done temporarily to stabilize the fracture for the patient’s comfort that does not support billing for fracture care and only the applicable E/M service should be reported. 

Remember that we cannot make assumptions about a patient’s clinical scenario based on the diagnosis or short statements such as “non-surgical” care. When billing for the separate service of fracture care we need to look at this from the perspective of treating the site. In the past I have been asked if a statement regarding pain control is enough along with the diagnosis to bill fracture care and the answer is no. The note must show what medical decision-making and stabilization are taking place to aid in the physical healing of the fracture site.

Reminders for Fracture Care Coding and Documentation

From a documentation perspective, the note for closed non-manipulative treatment is to include the following:

  • Statement regarding the definitive decision for treating the fracture (non-surgical/non-manipulative) 
  • Details related to the stabilization
    • This is to include the supplies/materials used or items that were applied/dispensed to the patient 
  • Plans related to the follow-up care that the patient will require

From a coding perspective consider the following when selecting the codes for billing:

  • Initial fracture care includes the application of the first cast or splint
    • The materials used for the initial casting or splinting can be separately reported, but reimbursement will depend on payer policy
    • If needed, future casting or splinting can be separately reported with a 58 modifier to represent a staged or related procedure by the same provider during an active post-operative period
  • Non-manipulative fracture care codes can carry the 90-day global period even though they are not surgical codes
  • X-rays are separately reportable and not a part of the global package
  • E/M services can be reported for additional conditions or injuries that are separately treated with the 24 modifier if being reported during the global period on a date after the initial treatment date

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