Fracture care coding can often present complexities and lead to misunderstandings, particularly when differentiating between fracture types and appropriate billing procedures. This guide aims to clarify the nuances of fracture care coding, drawing upon the expertise of the American Academy of Orthopaedic Surgeons (AAOS) to provide a definitive resource for healthcare professionals.
Understanding Fractures: Beyond the Basics
It’s crucial to dispel a common misconception: a fracture and a broken bone are one and the same. There’s no distinction, despite the colloquial term “hairline break” sometimes used. Fractures encompass any disruption in the continuity of a bone.
Classifying Fractures: A Spectrum of Breaks
The world of fractures is diverse, categorized by their pattern and characteristics. Some common types include:
- Transverse Fractures: The fracture line runs perpendicular to the long axis of the bone.
- Oblique Fractures: The fracture line is diagonal across the bone.
- Spiral Fractures: The fracture line spirals around the bone, often due to a twisting injury.
- Angulated Fractures: The bone fragments are misaligned at an angle.
- Displaced Fractures: The bone fragments are separated and not in anatomical alignment.
- Angulated and Displaced Fractures: Combining both misalignment and separation of bone fragments.
Beyond these common classifications, numerous specific fracture types exist, each often named after their discoverer or location. Examples include:
- Barton’s Fracture: Involving the distal radius and extending into the wrist joint. (ICD-10-CM S52.57- – Other fractures of distal end of radius, unspecified)
- Fissure Fracture: A crack in the outer layer of a long bone, not extending completely through.
- Jefferson’s Fracture: A fracture of the atlas vertebra (C1). (ICD-10-CM S12.001- – Unspecified fracture of first cervical vertebra [atlas], stable)
- Lead Pipe Fracture: Bone cortex compression and bulging on one side with a slight crack on the opposite side.
- Parry Fracture/Monteggia’s Fracture: Fracture of the proximal ulna with radial head dislocation. (ICD-10-CM S52.271- – Monteggia’s fracture of right ulna, initial encounter for closed fracture)
- Ping-Pong Fracture: A depressed skull fracture, typically in children, resembling a ping-pong ball indentation. (ICD-10-CM S02.0- – Fracture of vault of skull)
- Pott’s Fracture: Fracture of the distal fibula with injury to the tibial articulation, often involving the medial malleolus or deltoid ligament. (ICD-10-CM S82.84- – Pott’s fracture of lower leg, unspecified leg)
- Colles’ Fracture: Fracture of the distal radius with dorsal displacement of the distal fragment. A reverse Colles’ fracture involves volar displacement. (ICD-10-CM S52.52- – Colles’ fracture of distal radius)
Navigating this extensive list can be challenging for coding. Maintaining a medical dictionary or orthopaedic coding resource is essential for accurate interpretation of fracture documentation.
Fracture Treatment: Reduction and Fixation
The primary goal of fracture treatment is to facilitate optimal bone healing. Immobilization is paramount, often achieved through casting. Surgical intervention may be necessary to realign bone fragments accurately.
Before casting or surgical fixation, reduction, the process of restoring fractured bones to their correct anatomical position, is often required.
- Closed Reduction: Fracture manipulation performed externally, without surgical incision.
- Open Reduction: Surgical exposure of the fracture site to manipulate and reduce the bone fragments.
Accurate coding necessitates understanding the reduction type (open or closed), the affected body part (arm, leg, finger, etc.), and, when specified, the precise fracture location (e.g., femoral head vs. shaft).
Consider these X-ray examples illustrating different fracture types and reduction methods:
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Left X-ray: Demonstrates a minimally displaced fracture of the proximal phalanx of the long finger (ICD-10-CM S62.624- – Fracture of proximal phalanx of right middle finger). This could be treated with closed treatment without manipulation (CPT® 26720) or with manipulation (CPT® 26725), depending on the documented provider actions.
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Film A: The short arrow indicates a displaced index finger fracture (ICD-10-CM S62.621- – Fracture of proximal phalanx of right index finger), while the long arrow highlights multiple metacarpal fractures (ICD-10-CM S62.3- – Fracture of metacarpal bone).
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Film B: The short arrow points to percutaneous pin fixation (CPT® 26727) for a phalangeal shaft fracture. The long arrow indicates internal fixation using plates and screws for a metacarpal fracture (CPT® 26615).
Internal fixation methods also include rods and spheres, among others.
Billing for Fracture Care: AAOS Guidelines and Coding Approaches
The AAOS and the American Medical Association (AMA) recognize two primary methods for billing non-manipulative fracture care services, both detailed in CPT® Assistant publications.
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Fracture Global Fees:
The AAOS Guide to CPT® Coding for Orthopaedic Surgery defines fracture global fees as potentially encompassing the initial hospital or office visit in some payment models. CMS guidelines might allow reporting an E/M service with modifier 57 (Decision for surgery) during the global period if the initial visit established the need for the procedure. The global fee typically covers the initial cast or splint application and all follow-up visits within a 90-day period from the initial fracture management, excluding separately billed radiographs obtained by the physician. Recasting or re-splinting is billed separately on an “encounter” basis.
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Alternative Method for Fracture Fees:
AAOS outlines an alternative when fracture treatment doesn’t primarily involve a “procedure,” such as closed treatment without manipulation. In these instances, services can be itemized as office encounters. Examples include minimally displaced fractures of the fifth metatarsal, pelvis, or vertebral compression fractures. Office, hospital, and emergency department visits are coded accordingly, alongside separately billed injections, supplies, casts, splints, or treatment necessities.
Payer-specific guidelines are critical. For office-based fracture care, payers may require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code. Practices must determine whether global fracture care billing or itemization is more appropriate based on the clinical scenario and payer rules.
Coding Examples: Applying AAOS Guidelines
Example 1: Closed Reduction without Manipulation vs. E/M
Closed Reduction w/o Manipulation Reporting:
- Cast/splint/strapping: Included in the procedure code.
- X-rays and supplies: May be reported separately.
E/M Service Reporting:
- Cast/splint application, X-rays, and supplies: All may be reported separately in addition to the E/M service.
Closed reduction with manipulation has a 90-day global period. The initial cast, splint, and strapping, along with routine postoperative visits, are bundled into the global package. X-rays, DME, and casting/splinting supplies are billed separately. No separate billing for postoperative office visits within the global period is permitted for related care.
- Procedure Example: 26725 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each)
- Do not separately code for cast or splint application.
- Follow-up Visit Example: 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure)
- No separate E/M coding during the 90-day global period for related services.
- Casting and splinting supplies are reported separately.
Example 2: Fractured Clavicle and Extent of Care
Consider a patient with a non-displaced clavicle fracture, treated with a sling and PRN follow-up. Can fracture care be billed? Is this considered complete treatment if no scheduled follow-up is planned?
Remember, fracture care codes (and surgical procedures) have pre-operative, operative, and post-operative components built into their valuation.
Physician Reimbursement Breakdown (Approximate):
- 17% Preoperative
- 63% Operative
- 20% Postoperative
In this clavicle case with no planned follow-up, the postoperative component is essentially absent. Billing a fracture treatment code might be inappropriate. Similar logic applies to an ED physician treating a fracture without arranging follow-up; an E/M service is typically more suitable.
Example 3: Transfer of Postoperative Fracture Care
A patient injured in Utah undergoes surgery and returns home to New Jersey for follow-up. How is reimbursement handled?
Ideally, the Utah surgeon bills for the preoperative (17%) and operative (63%) portions, appending modifier 54 (Surgical care only) to the fracture care code if aware of the transfer. Communication and written documentation to the New Jersey orthopedist are essential for care transfer. The New Jersey orthopedist bills the same surgery code with modifier 55 (Postoperative care), receiving the 20% postoperative fee.
Real-world billing often deviates from this ideal. Surgeons may be reluctant to relinquish the postoperative portion, and physicians may be hesitant to accept reduced payment for another’s surgical work. In such scenarios, direct communication with the initial surgeon to negotiate fee splitting and corrected claim filing is often necessary. Without documented transfer of care, billing for postoperative care is not permissible.
Resources for Orthopaedic Coding Expertise
For coders specializing in orthopaedics, AAPC offers the Certified Orthopaedic Surgery Coder (COSC™) credential to validate expertise. Staying current with orthopaedic coding requires utilizing up-to-date medical coding books and resources. AAPC Coder provides a comprehensive code search engine to enhance claims processing efficiency.
Author Bio:
Cynthia Everlith, BSHA, CPC, CMA, is practice administrator for Arizona Hand and Wrist Specialists, a division of OSNA, PLLC. She has more than 25 years of experience in orthopaedic coding and practice management, and 16 years with her current practice. She is actively involved in workers’ compensation legislation and has worked closely with the Industrial Commission of Arizona and the Arizona Medical Association in rules affecting physicians. She has presented nationally and locally. She is a past American Association of Orthopaedic Executives (AAOE) Board of Directors and past president of AAPC’s Grand Canyon Coders Phoenix chapter. She serves on the AAOE Communication Council and Technology Task Force, and is president of the Arizona AAOE Chapter.
