Understanding Fracture Care Coding in the Emergency Department
Emergency physicians frequently manage fractures and dislocations, necessitating a firm grasp of Current Procedural Terminology (CPT) coding guidelines to ensure accurate and compliant billing. This guide addresses common questions regarding fracture care CPT coding, specifically focusing on the 2019 guidelines and their application in the emergency department (ED). It aims to clarify the nuances of closed fracture management, modifier usage, and the appropriate coding for various fracture care procedures performed in the ED setting.
1. Decoding Closed Fracture and Dislocation Management Codes
Emergency physicians have access to four distinct categories of closed management codes for fractures and/or dislocations:
- Closed treatment of fracture without manipulation: This code is applicable when the fracture is treated without any manual manipulation to realign the bone. An example is 25500 (Closed treatment of radial shaft fracture; without manipulation).
- Closed treatment of fracture with manipulation: This code is used when the physician manipulates the fractured bone to restore its alignment without surgically opening the site. An example is 26755 (Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation).
- Closed treatment of dislocation with fracture with manipulation: This code applies to dislocations complicated by a fracture, where manipulation is required to reduce the dislocation and align the fracture. An example is 23665 (Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation).
- Closed treatment of dislocation without fracture, with manipulation: This code is used for dislocations without associated fractures, requiring manipulation to restore normal joint alignment. An example is 23650 (Closed treatment of shoulder dislocation, with manipulation, without anesthesia).
2. Appropriate Use of Closed Fracture and Dislocation Management Codes in the ED
CPT guidelines state that the healthcare professional providing fracture/dislocation treatment should report the relevant treatment codes for the services they render. Crucially, if the emergency physician is providing initial treatment but will not be providing ongoing follow-up care, the -54 modifier (surgical care only) should be appended to the fracture/dislocation treatment code.
Most fracture and dislocation management codes are considered “global care” procedures, encompassing all routine pre-operative, intra-operative, and post-operative care. However, in the ED setting, physicians often provide initial stabilization and treatment, with subsequent care transferred to other specialists. Therefore, the -54 modifier is essential to accurately reflect the ED physician’s role. If a fracture treatment as defined by CPT is not performed, an Evaluation and Management (E/M) code should be reported instead.
The application of fracture and/or dislocation management codes in the ED does not hinge on whether the care is “restorative.” The codes are appropriate when the ED physician provides definitive closed treatment—with or without manipulation—as defined by CPT. The -54 modifier clarifies that the ED service is for initial care only.
3. Coding Fracture Care Without Manipulation: The Uncomplicated Toe Phalangeal Fracture Example
Emergency physicians can indeed code for fracture care even when manipulation is not required. CPT defines “closed treatment” as care where “the treatment site is not surgically opened (i.e., not exposed to the external environment nor directly visualized).” Closed treatment can encompass various methods, including application of casts, splints, or strapping, performed with or without manipulation.
However, it’s important to note that “casting, splinting, or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment.” This distinction is critical. If the ED physician applies a splint or cast for definitive treatment of the fracture (not just temporary stabilization), and the treatment meets the definition of closed treatment, then a fracture care code is appropriate.
Consider CPT code 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each). This code for an uncomplicated toe phalangeal fracture includes the closed treatment without manipulation. If the emergency physician provides definitive care for such a fracture—for instance, applying a walking boot or buddy taping—and does not anticipate providing the typical 90-day follow-up care associated with fracture management, appending the -54 modifier to code 28510 is appropriate.
Alt text: X-ray image illustrating a fracture of the toe phalanx, a common injury managed in emergency departments, often coded with 28510 for closed treatment without manipulation.
4. Moderate Sedation and Orthopedic Fracture/Dislocation Codes
The phrase “with anesthesia” in some orthopedic fracture and dislocation codes can cause confusion regarding moderate (conscious) sedation. CPT clarifies that moderate sedation is distinct from anesthesia services (general, regional, or monitored anesthesia care).
CPT defines moderate sedation as “…a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate.”
When a CPT code descriptor includes “with anesthesia” or “requiring anesthesia,” it signifies that the procedure typically necessitates anesthesia (general, regional, or monitored anesthesia care) due to its complexity or patient discomfort. The appropriate anesthesia code is reported separately when these types of anesthesia services are provided.
Crucially, moderate (conscious) sedation is not considered an anesthesia service in this context. Therefore, moderate sedation does not qualify as “anesthesia” for codes that specify “with anesthesia.” Furthermore, moderate sedation codes (99151-99157, 99148-99150 in 2019 CPT) can be reported separately, when appropriately documented, in addition to the orthopedic fracture and/or dislocation procedure code if moderate sedation is administered by the emergency physician.
5. Separate Coding for X-Ray Interpretation
Surgical procedures, including orthopedic procedures, are considered to encompass the operation itself, local anesthesia (infiltration, metacarpal/digital block, or topical), and routine, uncomplicated follow-up care. However, radiological interpretations are not included in the surgical package.
Therefore, emergency physicians can separately code and bill for X-ray interpretations (e.g., 71045-71048 for chest X-rays, 73560-73565 for knee X-rays, etc.) in addition to orthopedic procedure codes, provided that the interpretation is performed, documented, and meets the requirements for separate reporting. Documentation should clearly indicate that the physician provided a formal interpretation of the X-ray, beyond simply reviewing it as part of the procedural service.
6. Applying Splint/Strap Procedure Codes (CPT 29000–29799)
CPT codes in the range 29000–29799 are designated for splinting and strapping services, described as procedures to “stabilize, protect or provide comfort.” Emergency physicians can report these codes for the initial application or replacement of splints or straps.
However, a crucial distinction exists: if the splint/strap application is part of restorative care (definitive fracture or dislocation management), the appropriate orthopedic service code (fracture or dislocation management code) should be used instead. You cannot use both splint/strap codes and fracture management codes for the same restorative care.
For instance, if an emergency physician applies a long arm splint as definitive treatment for a forearm fracture, they would use the fracture care code (e.g., 25500 or 25574 with manipulation) and not a splinting code (e.g., 29105). Conversely, if a splint is applied for temporary stabilization or comfort, prior to definitive fracture care by another provider, or for conditions other than fracture management, a splint/strap code might be appropriate.
Furthermore, if a physician supervises the application of a splint or strap by other staff (e.g., an emergency department technician under the physician’s direction), the physician can report the splint/strap application procedure code if they are actively involved in the decision-making and supervision of the procedure.
7. Billing for Prefabricated Splint Application
The coding for prefabricated or “off-the-shelf” splints differs from custom-made splints. When an emergency physician applies a prefabricated splint, the facility (hospital or clinic) should report the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the supply of the prefabricated splint (e.g., L3908 for a wrist-hand-finger orthosis, prefabricated, off-the-shelf).
The application of a prefabricated splint by the physician is considered included in the Evaluation and Management (E/M) service and is not separately billable using a CPT splint application code. The physician’s service is the E/M encounter where the need for and application of the splint are determined and carried out.
8. Common Splinting and Strapping Procedures and RVUs
| Description of Procedure | CPT Code | Total RVUs |
|---|---|---|
| Application of long arm splint (shoulder to hand) | 29105 | 1.25 |
| Application of a short arm splint (forearm to hand); static | 29125 | 1.22 |
| Application of a short arm splint (forearm to hand); dynamic | 29126 | 1.49 |
| Application of finger splint; static | 29130 | 0.87 |
| Strapping; thorax | 29200 | 0.54 |
| Strapping; shoulder (e.g., Velpeau) | 29240 | 0.89 |
| Strapping; elbow or wrist | 29260 | 0.56 |
| Strapping; hand or finger | 29280 | 0.60 |
| Application of long leg splint (thigh to ankle or toes) | 29505 | 1.58 |
| Application of short leg splint (calf to foot) | 29515 | 1.50 |
| Strapping; hip | 29520 | 0.54 |
| Strapping; knee | 29530 | 0.53 |
| Strapping; ankle and/or foot | 29540 | 0.51 |
| Strapping; toes | 29550 | 0.33 |
RVUs: Relative Value Units
This table outlines common splinting and strapping procedures performed in emergency medicine, along with their corresponding CPT codes and total Relative Value Units (RVUs), which reflect the relative value of the service for reimbursement purposes.
9. Fracture Care Codes and Temporary Stabilization (-56 Modifier Inappropriateness)
The -56 modifier (“Preoperative Management Only”) is not appropriate for reporting temporary stabilization of a fracture before surgical intervention. A temporary cast, splint, or strap is not considered part of pre-operative care in the context of fracture management coding.
In situations where an emergency physician provides temporary stabilization (e.g., applies a splint in the ED before the patient is referred to an orthopedic surgeon for definitive surgical repair), it is appropriate to report an Evaluation/Management (E/M) service code for the patient encounter, along with a cast/splint/strap code (if a separately billable splint or strap is applied, as discussed in FAQ #6). The E/M code captures the physician’s evaluation and management of the patient’s condition, while the splint/strap code, if applicable, covers the application of the device.
10. Billing E/M Services in Addition to Orthopedic Procedure Codes
It is possible to bill an Evaluation/Management (E/M) service code in addition to orthopedic procedure codes (fracture/dislocation management or splint/strap services) under specific circumstances.
If the E/M service is for a significant, separately identifiable medical service that is distinct from and not directly related to the orthopedic care provided, an E/M code with the -25 modifier (significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can be used. This signifies that the E/M service is beyond the typical pre- and post-procedure care associated with the orthopedic service.
Alternatively, if the E/M service is performed to make the initial decision for surgery (though less common in ED fracture care which is typically initial management not definitive surgery decision), the -57 modifier (decision for surgery) could be considered, though -25 is far more typical in the ED context.
For example, if a patient presents to the ED after a motor vehicle accident with a fractured wrist and also multiple other injuries (e.g., head laceration, abdominal pain), the emergency physician might bill an E/M code (with -25 modifier) for the comprehensive evaluation and management of the multiple injuries, in addition to the appropriate fracture care code for the wrist fracture management. The documentation must clearly support the separately identifiable nature of the E/M service.
11. Nasal Bone Fracture Coding: CPT 21310 and 21315
There was a change in coding guidelines regarding nasal bone fractures. CPT code 21310 (Closed treatment of nasal bone fracture without manipulation) was deleted in CPT 2022. As per CPT 2022 guidelines, “to report closed treatment of nasal bone fracture without manipulation or stabilization, use appropriate E/M code.” This means that for simple nasal bone fractures that do not require manipulation, only an E/M code should be reported, not a specific fracture care code.
CPT 21315 (Closed treatment of nasal bone fracture; with manipulation) remains active. This code is used when the physician manipulates the fractured nasal bones to achieve proper alignment, typically using nasal elevators or forceps. Once the bones are realigned, the fracture does not require additional stabilization in most cases when coded with 21315.
Alt text: Image depicting a physician performing closed reduction of a nasal fracture using specialized instruments, a procedure appropriately coded with CPT 21315.
12. “Open” vs. “Closed” Fracture Treatment: CPT Definitions
CPT definitions emphasize that fracture care coding should be based on the type of treatment rendered, not solely on the type of fracture itself.
Open treatment is defined as requiring a surgical incision to expose the fracture site for direct visualization. This is typically performed in the operating room by orthopedic surgeons.
Closed treatment means that the fracture site is not surgically opened. Emergency physicians primarily provide closed treatment, even when managing open fractures (fractures where the bone protrudes through the skin). In the ED, the initial management of an open fracture typically involves wound care, stabilization, and splinting (closed treatment), before potential surgical intervention in the operating room (open treatment) by a specialist.
13. Rib Fracture Coding: CPT 21800 Retirement
CPT code 21800 (Closed treatment of rib fracture, uncomplicated) has been retired and is no longer a valid code. There is no specific CPT code for the closed treatment of an uncomplicated rib fracture. Management of rib fractures in the ED, if uncomplicated, is typically reported with an E/M code. If procedures such as intercostal nerve blocks are performed for pain management of rib fractures, these may be separately reportable with appropriate coding and documentation.
14. Medicare’s Global Days for Common Fracture Care Procedures
| Code | Description | Post-Op Days |
|---|---|---|
| 21315 | Closed treatment of nasal bone fracture with manipulation | 0 |
| 23500 | Closed treatment of clavicular fracture, without manipulation | 90 |
| 23650 | Treat shoulder dislocation, without manipulation | 90 |
| 23665 | Treat shoulder dislocation with fracture and manipulation | 90 |
| 26755 | Treat finger or thumb fx, with manipulation | 90 |
| 28510 | Treat toe fracture, without manipulation | 90 |
Medicare’s Global Days indicate the number of post-operative days included in the global surgical package for a given procedure. For procedures with 90-day global periods, the global package typically encompasses routine follow-up care within 90 days of the procedure. For procedures with 0-day global periods, like 21315, there is no global period, and follow-up care is generally billed separately if provided. Understanding global days is important for billing and reimbursement, particularly when considering the -54 modifier for surgical care only in the ED.
15. Common Orthopedic Procedures in the ED and RVUs
| Description of Procedure | CPT Code | Total RVUs |
|---|---|---|
| Closed treatment of distal radius fracture; without manipulation | 25600 | 10.18 |
| Closed treatment of radial head subluxation; with manipulation | 24640 | 2.42 |
| Closed treatment of shoulder dislocation; with manipulation | 23650 | 9.40 |
| Closed treatment of hip dislocation, traumatic; without anesthesia | 27250 | 5.37 |
| Closed treatment of patellar dislocation; without anesthesia | 27560 | 10.64 |
| Closed treatment of post hip arthroplasty dislocation; without anesthesia | 27265 | 12.90 |
| Closed treatment of proximal humeral fracture; without manipulation | 23600 | 9.91 |
This table lists several common orthopedic procedures frequently performed by emergency physicians, along with their CPT codes and total RVUs. These procedures represent a significant portion of fracture and dislocation management in the emergency setting and demonstrate the scope of orthopedic care provided in the ED.
Conclusion: Navigating Fracture Care CPT Coding
Accurate fracture care CPT coding is essential for emergency physicians. Understanding the nuances of closed treatment, modifier usage, and the distinctions between splinting/strapping codes and fracture management codes is crucial for compliant and appropriate billing. This guide, focusing on 2019 guidelines, provides a framework for navigating these complexities. Always refer to the most current CPT guidelines and coding resources for the most up-to-date information and consult with coding experts when facing complex scenarios.
Resources:
- CPT Assistant, September 2019, “Reporting Nasal Bone Vs Septal Fracture Treatment,” Page 3.
- CPT Assistant, November 2019, “Coding Correction: Reporting Fracture and Restorative Care and Dislocations,” Page 12.
- CPT Assistant, May 2022, “Reporting Closed Treatment of Nasal Bone Fracture,” Page 5.
- 2019 CPT Professional Edition
- ACEP Moderate Sedation FAQ (link to actual FAQ if available)
