skeleton pointing up
Closed fracture care coding, especially concerning treatments that involve manipulation, has long been a complex area within medical billing. This article aims to clarify the 2023 fracture care coding guidelines, specifically focusing on scenarios involving fracture reduction and manipulation. Understanding the nuances of these guidelines is crucial for accurate claim submissions and appropriate reimbursement. Navigating the decision between reporting a fracture care code versus an Evaluation and Management (E/M) service is a common challenge, particularly when restorative care is provided. The American Medical Association (AMA) acknowledges the validity of both coding approaches under specific circumstances. Let’s delve into the definitions and coding practices that will ensure correct reporting in 2023.
Understanding Key Definitions in Fracture Care Coding
To accurately apply fracture care coding guidelines in 2023, it’s essential to differentiate between restorative and definitive care:
-
Restorative Care (Closed Treatment WITH Manipulation): This involves procedures aimed at restoring the fractured bone to its correct anatomical position. Manipulation techniques can include traction, flexion, extension, and rotational adjustments, followed by immobilization using casts, splints, or braces.
- In situations where an Emergency Department (ED) physician or Advanced Care Practitioner (ACP) provides restorative care but will not manage the patient’s follow-up, it is appropriate to report a Closed Fracture Care (CFC) code with the -54 modifier (surgical care only). Conversely, orthopedic specialists who assume post-operative care can report the same CFC code but append the -55 modifier (post-operative care only).
-
Definitive Care (Closed Treatment WITHOUT Manipulation): This type of care typically involves pain management and immobilization, such as applying a cast, strapping, or splint, without any manipulative reduction of the fracture.
- When a physician or ACP in the ED provides definitive care and will not be responsible for follow-up, the recommended coding practice is to report an appropriate E/M service code in conjunction with the relevant cast or splint application code. This approach accurately reflects the services rendered in the absence of fracture manipulation.
For displaced fractures that necessitate restorative care, it is generally appropriate to report both an initial E/M service and the corresponding closed fracture care code with manipulation. To properly indicate that the decision for surgery (which in this context refers to the fracture reduction procedure within a 90-day surgical global period) was made during the initial encounter, append the -57 modifier to the E/M service code. This crucial modifier allows for the distinct reporting of both the evaluation and management service and the subsequent manipulation procedure.
Example Scenario for Restorative Fracture Care Coding in 2023
Consider a patient presenting to the emergency department with a displaced distal radius fracture. The physician evaluates the patient, confirms the fracture, and performs a closed reduction with manipulation to realign the bone fragments. Following successful reduction, a cast is applied for immobilization. In this scenario, the appropriate coding would include:
- An E/M code (e.g., 99284 or 99285 depending on the complexity of the ED visit) with the -57 modifier to indicate the decision for surgical treatment (fracture reduction) was made.
- The specific closed fracture care code with manipulation for a distal radius fracture (e.g., 25605 – Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with manipulation).
This coding combination accurately reflects the comprehensive services provided, from the initial evaluation and decision-making to the restorative fracture care with manipulation.
Navigating Complex Coding Scenarios: Plot Twists in Fracture Care
Coding becomes more intricate when different providers within the same group practice contribute to the fracture care. It’s important to remember that Medicare and many other payers consider all providers within a group practice as a single entity. This “single provider” concept has significant implications for how global surgical packages and modifiers are applied.
Plot Twist Example One: Split Responsibility within a Group Practice
Scenario: A Physician Assistant (PA) in the Emergency Department performs the closed reduction of a fracture. However, a physician within the same group practice provides all subsequent post-operative care in the clinic setting. How should this be coded under 2023 fracture care coding guidelines?
In this situation, the PA can report both the initial visit (potentially an ED E/M service or consultation if applicable) and the closed fracture reduction procedure code. When reporting the reduction code, it’s essential to consider the global surgery modifiers. While the application of global modifiers within the same group practice can be complex, they may be necessary to accurately reflect the division of services.
Considerations:
First Consideration: Place of Service (POS) and Reimbursement Rates
The fracture reduction was performed in the Emergency Department (POS 23), which typically has facility-based reimbursement rates. The post-operative care is provided in an office setting (POS 11), which has a higher reimbursement rate reflecting practice overhead costs. Using global surgery modifiers may allow for the separation of these services and potentially optimize reimbursement to reflect the different POS and cost structures. Without modifiers, the entire global service might be attributed to the PA’s initial reduction and reimbursed at the generally lower facility rate associated with the ED and the PA’s rate (85% of the Physician Fee Schedule).
Second Consideration: Provider Reimbursement Rates
Physicians are reimbursed at 100% of the Physician Fee Schedule (MPFS), while PAs are reimbursed at 85%. If the global surgical package is not appropriately unbundled using modifiers, the entire service, including the physician’s post-operative care, might be inadvertently reimbursed at the PA’s rate if billed under the PA’s NPI. Using modifiers can help ensure that the physician’s portion of the service is reimbursed at the correct physician rate.
Third Consideration: Accurate Reporting
The paramount consideration should always be accurate and transparent coding that reflects who performed which service, where, and when. While financial considerations are important, coding compliance and ethical billing practices must take precedence. Using modifiers in this scenario allows for a more precise representation of the service distribution within the group practice.
Global Surgery Modifiers Relevant to Fracture Care Coding 2023:
- -54 Modifier: Surgical Care Only (69% of the global package Relative Value Units (RVUs)): Use when the provider performs the surgical procedure (e.g., fracture reduction) but relinquishes responsibility for post-operative management.
- -55 Modifier: Post-Operative Care Only (21% of global package RVUs): Use when the provider assumes responsibility for only the post-operative management portion of the global surgical package.
- -56 Modifier: Pre-Operative Care Only (10% of global package RVUs): Less commonly used in fracture care scenarios, but applicable if a provider only performs the pre-operative evaluation and decision for surgery but not the surgery or post-operative care.
- -57 Modifier: Decision for Surgery (Applied to E/M codes): Used with an E/M service code to indicate that the decision to perform a major surgical procedure (90-day global period) was made during that E/M encounter.
Plot Twist Example Two: Stabilization without Manipulation in the ED
Scenario: A PA in the emergency room evaluates a patient with a fracture and applies a cast or splint for stabilization but does not perform fracture reduction or manipulation. The patient is then scheduled for follow-up with an Orthopedic Surgeon in the office.
In this case, according to 2023 fracture care coding guidelines, it is appropriate for the PA to report an E/M service code reflecting the ED visit and a separate code for the application of the cast or splint. Since no fracture manipulation was performed by the PA, a closed fracture care code with manipulation is not applicable. The orthopedic surgeon, upon seeing the patient in follow-up, will then determine the definitive treatment plan. Depending on whether the orthopedic surgeon performs a reduction in the office or provides definitive care without manipulation, they will bill accordingly. They may report a fracture care code if they perform a reduction, or continue with E/M services and casting/splinting codes if they opt for non-manipulative management.
Conclusion: Case-by-Case Consideration in Fracture Care Coding 2023
Accurate fracture care coding in 2023, particularly in complex scenarios involving manipulation and shared responsibility within group practices, requires careful consideration of each case individually. Understanding the definitions of restorative and definitive care, appropriate use of modifiers, and the implications of the “single provider” concept for group practices are essential. By adhering to these guidelines and staying updated on payer-specific rules, providers can ensure compliant and accurate billing for fracture care services.
Resources:
AAPC: Fractures 101-Let’s Cover the Basics
AAPC: Tricky ED Fracture Care Coding%20reports%20the%20fracture%20care. “Tricky ED Fracture Care Coding”)
AAPC: Billing Fractures in the ED
INFINX (blog): How to Accurately Code Closed Fracture Care
ACEP: Orthopedic Fracture / Dislocation Management FAQ
CMS: Billing and Coding Fracture Care
CMS: Physician Fee Schedule Look-up Tool
MSHBC: Closed Fracture Care Tip Sheet
Alt text for image: A skeleton figure humorously pointing upwards to emphasize the importance of understanding fracture care coding guidelines in 2023, relevant to medical billing and compliance.
