Fracture care within the emergency department (ED) presents unique coding challenges. Navigating the nuances of billing for these services requires a clear understanding of different treatment types and provider responsibilities. This guide will clarify the concept of Definitive Care Coding in fracture management, ensuring accurate and compliant billing practices for ED services.
Understanding Definitive vs. Restorative Fracture Care in the ED
When it comes to fracture care in the emergency setting, the initial step is to differentiate between two primary types of care: definitive care and restorative care. This distinction is crucial because it directly impacts the coding and billing process.
Definitive Care Explained
Definitive care, also known as non-manipulative care, focuses on providing immediate pain relief and stabilizing the fracture. This is achieved primarily through immobilization. Definitive care is typically appropriate for fractures that are non-displaced or minimally displaced, often involving smaller bones. It can also be applied to stable long bone fractures with minimal or no displacement.
Examples of definitive care in practice include:
- Phalangeal fractures: Treated with splinting or buddy taping to immobilize the finger.
- Stable, non-displaced rib fractures: Managed with taping and respiratory therapy, such as breathing exercises. (Note that braces or splints are typically avoided for rib fractures as they can restrict breathing.)
- Nasal fractures: Treated with ice packing and pain medication.
For coding purposes, definitive care is reported using CPT® codes that specify “Closed treatment of [XYZ] fracture without manipulation.” Here are some CPT® code examples relevant to definitive care coding:
- 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’s important to note that CPT® code 21800 (Closed treatment of rib fracture, uncomplicated, each) was deleted in 2015. Currently, uncomplicated rib fracture treatment is reported using Evaluation and Management (E/M) codes, as per the CPT® 2015 guidelines.
Restorative Care Explained
Restorative care, in contrast to definitive care, involves manipulation to realign displaced fractures back to their correct anatomical position. This type of care, also termed manipulative care, is necessary when a fracture results in bone fragments being out of place.
Physicians performing restorative care utilize various manipulative techniques. These may include traction, flexion, extension, and medial or lateral rotation to reposition the displaced bone fragments. Once proper alignment is achieved, the fractured body part is immobilized using a cast or splint.
Crucially, if manipulation fails to restore the bone to its original anatomical position, the procedure is deemed unsuccessful. In such cases, the patient typically requires referral to a specialist for more advanced care.
Restorative care is coded using CPT® codes that describe “Closed treatment of [XYZ] fracture with manipulation.” Examples of CPT® codes for restorative care include:
- 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
Definitive Care Coding: Billing Responsibilities in the ED
A key aspect of definitive care coding is understanding who is responsible for billing for fracture care services provided in the ED. Generally, ED physicians or qualified healthcare professionals can report fracture care in the ED when they deliver treatment comparable to what a specialist, such as an orthopedist, would provide.
However, if an orthopaedic physician is called into the ED to treat the fracture, the orthopedist, not the ED physician, should report the fracture care.
The scenario becomes more nuanced when a patient receives definitive care in the ED and is then referred for follow-up. Here’s how billing responsibilities are determined in these situations:
Scenario 1: Follow-up with a Specialist
If a patient receives definitive care in the ED and is advised to follow up with a specialist (orthopaedist) within three to five days, the fracture care billing typically goes to the specialist. This is because the specialist is anticipated to provide the comprehensive fracture care, including ongoing treatment and management.
- Example: A patient presents to the ED with a distal radius fracture. The ED physician applies a splint and instructs the patient to see an orthopaedist immediately. In this case, the ED physician reports the splint application (CPT® code 29125 – Application of short arm splint (forearm to hand); static), while the orthopaedist bills for the fracture care itself.
Scenario 2: Definitive Care as Complete Treatment
Conversely, if a patient receives definitive care in the ED and is referred to a specialist for follow-up within three to five days, but the ED physician has provided the complete fracture treatment, then the ED provider bills for the fracture care. The follow-up is considered for the next level of care, if needed, but the initial fracture management is attributed to the ED.
- Example: A patient has a distal radius fracture. The ED physician applies a splint and advises follow-up with an orthopaedist in three to five days. In this scenario, the ED physician reports the fracture care (e.g., 25600 – Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) with modifier 54 (Surgical care only) appended.
Key Points to Remember for Definitive Care Coding in Fracture Management
Accurate definitive care coding in the ED requires attention to several important considerations. Drawing on guidance from CGS Medicare, remember these key points:
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Global Fracture Care: “Global fracture care” encompasses the entire process of treating a fracture, including necessary follow-up care until the fracture is healed. This includes both restorative care and subsequent management.
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Restorative Care Threshold for Fracture Care Billing: To bill for fracture care (beyond simple splinting after straightening a limb), the treatment must meet the definition of “restorative” care or constitute a significant portion of the global fracture care. Physicians who provide this level of treatment can bill the appropriate CPT® code for fracture treatment and receive reimbursement for the global surgical package of care.
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ED Physician Billing with Modifier 54: ED physicians (and authorized non-physician practitioners) who provide fracture treatment (meeting the restorative care threshold or significant portion of global care) but do not provide follow-up care can bill the fracture treatment code with CPT® modifier 54. This indicates “Surgical care only.”
- Example: A patient has a displaced metacarpal fracture. The ED physician manipulates and reduces the fracture, then applies a splint. This should be coded as 26605-54.
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Specialist Billing with Modifier 55: A non-ED physician, such as an orthopaedic surgeon, who provides casting, follow-up evaluation and management (E/M), and continues care until the fracture heals, can bill the fracture treatment code with CPT® modifier 55. This signifies “Postoperative management only.”
- Example: A patient receives initial fracture treatment in the ED. The patient then follows up with an orthopaedist who handles casting, splinting, and ongoing treatment until healing. The ED physician would report 26600-54 (Closed treatment of metacarpal fracture, single; without manipulation, each bone – with modifier 54), while the orthopaedist would report 26600-55.
By understanding the principles of definitive care coding, the distinction between definitive and restorative care, and the nuances of billing responsibilities, healthcare providers in the ED can ensure accurate and compliant coding for fracture management services.
Disclaimer: This information is for educational purposes only and should not be considered as definitive coding or legal advice. Always consult official coding guidelines and seek expert advice for specific coding and billing situations.
(Source: Adapted from original article and CGS Medicare guidelines)
