Emergency department (ED) billing for fracture care is often misunderstood. Contrary to common misconceptions, emergency physicians can and regularly do provide fracture care that is billable. The key to appropriate billing lies in distinguishing between restorative care (manipulation) and definitive care (comprehensive treatment). Understanding these distinctions based on fracture care coding guidelines is crucial for accurate claim submissions and revenue integrity in the ED setting.
Restorative Care: Manipulation in the ED
Restorative care in fracture management typically involves manipulation to restore the bone’s alignment. In the ED, this is frequently necessary for certain types of fractures. Common fractures requiring manipulation that are often seen and treated in the emergency department include:
- Finger fractures
- Toe fractures
- Metacarpal fractures
- Distal fibular fractures
- Bimalleolar and trimalleolar ankle fractures
- Distal radius fractures
To ensure proper coding and billing for restorative fracture care, detailed procedural documentation by the physician is essential.
Example Scenario: Consider a patient presenting to the ED with significant wrist pain following a fall. An X-ray confirms a distal radius fracture. The emergency physician performs a closed reduction, manipulating the fractured bone back into alignment. In such cases, coders should report the appropriate code for closed treatment of a distal radius fracture with manipulation. For instance, CPT code 25605 (Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) would be applicable.
Definitive Care: Comprehensive Fracture Management in the ED
Definitive care, in the context of fracture management in the ED, refers to providing complete and comprehensive treatment, even without manipulation. Emergency physicians often deliver definitive care for specific fracture types, including:
- Finger fractures
- Toe fractures
- Clavicle fractures
A frequently overlooked but billable service in the ED is the definitive care provided for phalanx fractures, coded as 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each). In many cases of phalanx fractures, emergency physicians provide comprehensive definitive care that mirrors the treatment a specialist would offer in the initial stages. This includes:
- Pain management for the patient.
- Thorough review of medical history and documentation.
- Detailed explanation of the expected symptom progression, healing timeline, and potential complications.
- Application of buddy taping to stabilize the injured toe with an adjacent toe.
Following this definitive care, the patient is typically discharged with or without pain medication prescriptions and instructions for follow-up.
The timeframe for specialist follow-up is a key indicator to differentiate definitive care from palliative care. Definitive care usually implies a standard follow-up timeframe of five to seven days. If a specialist consultation is required in less than a week, it suggests the ED physician likely provided only palliative care, not definitive fracture management.
E/M Documentation and Modifier Application
When evaluating and treating a patient with a fracture, a detailed examination is generally necessary. Physicians must meticulously document the extent of the injury, assess neurovascular status, and identify any associated injuries. Comprehensive documentation is crucial to support the level of Evaluation and Management (E/M) services billed. Fracture treatment E/M services in the ED often begin at level IV due to the complexity and required detail.
Because fracture care codes are considered major surgical procedures with a 90-day global period, it’s essential to use appropriate modifiers when billing E/M services alongside fracture care. Modifier 57 (Decision for surgery) should be appended to the E/M code when the decision to perform fracture care is made during the same ED encounter.
Furthermore, when the emergency physician provides fracture care but the patient requires follow-up with a specialist for ongoing management, modifier 54 (Surgical care only) should be appended to the fracture care CPT code. This modifier informs the payer that the ED provided the preoperative and intraoperative phases of care, while postoperative management will be handled by another provider. Using modifier 54 typically results in the ED physician receiving approximately 70 percent of the total reimbursement for the fracture care service, acknowledging the shared responsibility of care.
By adhering to fracture care coding guidelines and correctly applying modifiers, EDs can ensure accurate billing and appropriate reimbursement for the essential fracture care services they provide.
