Fracture care in medical coding, particularly within the emergency department (ED), presents unique challenges for healthcare professionals. Accurate coding is crucial for appropriate reimbursement and reflects the complexity of services provided to patients with bone fractures. This guide will break down the essentials of What Is Fracture Care In Medical Coding, focusing on the different types of care and billing responsibilities in the ED setting.
Understanding Fracture Care Types
In the emergency department, fracture care is broadly categorized into two main types: definitive care and restorative care. Understanding the distinction between these two is fundamental for correct medical coding.
Definitive Care
Definitive care, also known as non-manipulative care, focuses on pain management and stabilizing the fracture through immobilization. This type of care is typically administered for fractures that are not significantly displaced or are minimally displaced, especially in smaller bones. It can also be applied to long bone fractures with minimal to no displacement.
For instance, a fracture in a finger phalanx might be treated with a simple splint or buddy taping to immobilize it. Similarly, a stable, non-displaced rib fracture may be managed with taping and breathing exercises, avoiding braces that could restrict chest expansion. Nasal fractures often receive definitive care with ice packs and pain medication.
Definitive care is coded using CPT® codes that specify “Closed treatment of [XYZ] fracture without manipulation.” Examples of these codes include:
- 21310 – Closed treatment of nasal bone fracture without manipulation
- 23500 – Closed treatment of clavicular fracture; without manipulation
- 26720 – Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each
- 28510 – Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each
It is important to note code changes. For example, in the past, code 21800 (Closed treatment of rib fracture, uncomplicated, each) was used, but it was deleted in 2015. Currently, uncomplicated rib fracture treatments are reported using Evaluation and Management (E/M) codes, according to the CPT® 2015 guidelines.
Restorative or Manipulative Care
Restorative care, also known as manipulative care, is required for displaced fractures. This involves manipulation to reposition the fractured bone fragments back to their correct anatomical alignment. Physicians utilize various manipulative techniques, including traction, flexion, extension, and rotation, to achieve proper alignment. Following successful manipulation, the fractured area is immobilized using a cast or splint.
If manipulation fails to restore the bone fragments to their original position, the procedure is deemed unsuccessful, and the patient is typically referred to a specialist for further intervention.
Restorative care is reported with CPT® codes that describe “Closed treatment of [XYZ] fracture with manipulation.” Examples of these codes are:
- 26605 – Closed treatment of metacarpal fracture, single; with manipulation, each bone
- 26725 – Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each
- 27762 – Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction
- 28435 – Closed treatment of talus fracture; with manipulation
- 28515 – Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each
Who Bills for Fracture Care in the ED?
Determining who should bill for fracture care in the ED hinges on who provides the definitive or restorative treatment. If an ED physician (or another qualified healthcare professional within the ED) delivers fracture care that is equivalent to the treatment typically provided by a specialist like an orthopedist, then the ED can bill for the fracture care.
However, if an orthopedic physician is called into the ED to manage the fracture, the orthopedic physician, not the ED physician, is the one who reports the fracture care services.
Furthermore, the timing of follow-up care with a specialist impacts billing responsibilities. If a patient receives definitive care in the ED and is then referred to an orthopedist for follow-up within a short timeframe (e.g., three to five days), the billing for fracture care often depends on the anticipated scope of care by each provider.
Example 1: A patient presents with a distal radius fracture. The ED physician applies a splint and instructs the patient to immediately follow up with an orthopedist. In this scenario, the ED physician bills for the splint application (e.g., CPT® code 29125 for a short arm splint), while the orthopedist bills for the fracture care itself, as they are expected to provide comprehensive fracture management.
Example 2: Consider a similar case where a patient has a distal radius fracture, and the ED physician applies a splint, but the follow-up with an orthopedist is scheduled in three to five days. In this instance, because the ED physician provided what is considered the complete initial fracture care in the ED setting, the ED physician can report the fracture care code (e.g., 25600 for closed treatment of distal radial fracture without manipulation) and append modifier 54, indicating “Surgical care only.” This signifies that the ED provided the fracture reduction or stabilization, but not the subsequent follow-up management.
Fracture Care Points to Remember
When it comes to reporting fracture care in the ED, several crucial points should be kept in mind to ensure accurate medical coding and billing practices. These points are adapted from guidelines provided by CGS Medicare:
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Global Fracture Care: “Global fracture care” encompasses the entire process of treating a fracture, including the initial treatment and all necessary follow-up care until the fracture is healed. This full scope of care is usually provided by specialists outside the ED setting in most fracture cases requiring more than definitive care.
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Restorative Care and Billing: To bill for fracture care beyond simple splinting in the ED, the treatment must meet the criteria for “restorative” care. This generally means it involves more than just applying a splint after straightening the limb; it typically requires manipulation to reduce the fracture. Physicians who provide this level of treatment and a significant portion of the global fracture care package can bill the appropriate CPT® code for fracture treatment.
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ED Physicians and Modifier 54: ED physicians who provide fracture treatment (as described above for restorative care) but do not manage the follow-up care can submit a claim for the fracture treatment code with CPT® modifier 54. This modifier is essential for indicating that only the surgical care component of the global service is being billed.
Example: A patient with a displaced metacarpal fracture is treated in the ED. The ED physician manipulates and reduces the fracture and applies a splint. This service should be coded as 26605-54.
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Non-ED Physicians and Modifier 55: Conversely, a non-ED physician, such as an orthopaedic surgeon, who takes over the care after the ED visit and provides casting, follow-up evaluations, and management until the fracture heals, may submit a claim for the fracture treatment code with CPT® modifier 55, representing “Postoperative management only.”
Example: If a patient with a metacarpal fracture receives initial treatment in the ED and then follows up with an orthopedist who applies the cast, provides ongoing treatment, and manages the fracture until it heals, the ED physician would report 26600-54 (if they provided fracture care as surgical care only), while the orthopedist would report 26600-55.
Understanding what is fracture care in medical coding within the emergency department is crucial for accurate billing and compliance. By differentiating between definitive and restorative care, and by correctly applying modifiers, healthcare providers can ensure they are appropriately reimbursed for the essential services they provide to patients with fractures.
