Fracture Care Coding Scenarios: Mastering Closed Fracture Treatment with Manipulation

skeleton pointing up

Navigating the complexities of closed fracture care coding, especially when manipulation is involved, has long been a point of discussion and confusion in medical billing. While coding for fracture care without manipulation presents its own set of challenges, our focus here will be on scenarios that necessitate reduction – and how to code them accurately. Deciding between a fracture care code and an Evaluation and Management (E/M) service, or potentially both, is a common dilemma. This article aims to clarify these situations, offering best practice recommendations endorsed by the AMA, along with essential caveats for proper reporting in various Fracture Care Coding Scenarios.

Decoding Fracture Care: Restorative vs. Definitive Treatment

Understanding the nuances of fracture care coding hinges on differentiating between restorative and definitive treatment. These terms are crucial in determining the appropriate coding approach for different fracture care coding scenarios.

Restorative Care: Closed Treatment with Manipulation (Reduction): This involves procedures aimed at physically realigning the fractured bone to its correct anatomical position. Techniques employed can include traction, flexion/extension, and medial/lateral rotation, always followed by immobilization (casting, splinting).
- In scenarios where an Emergency Department (ED) physician or Advanced Clinical Practitioner (ACP) provides restorative care but will not manage the patient’s post-operative follow-up, they should report a Closed Fracture Care (CFC) code appended with the -54 modifier (Surgical Care Only). Conversely, an orthopedic specialist assuming post-operative care would report the same CFC code but with the -55 modifier (Post-operative Care Only).
Definitive Care: Closed Treatment without Manipulation: This approach typically focuses on pain management and immobilization (casting, strapping, splinting, etc.) without any attempt to reduce or realign the fracture.
- If a physician or ACP provides definitive care and will not be managing follow-up, the most appropriate coding strategy for the ED provider is to report the service using an appropriate E/M code in conjunction with the relevant cast application codes. This fracture care coding scenario avoids the complexities of global surgical packages when follow-up care is transferred.

For displaced fractures requiring restorative care, it is appropriate to report both an initial visit using an E/M service code and the corresponding closed fracture care with manipulation code. To accurately reflect that the decision for surgical intervention (within a 90-day surgical global period) was made during the initial encounter, append the -57 modifier (Decision for Surgery) 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, ensuring correct reimbursement and adherence to fracture care coding guidelines.

Navigating Complex Fracture Care Coding Scenarios: Plot Twists in Practice

Often, fracture care isn’t straightforward. Physicians or Advanced Practice Providers (APPs) may only provide a segment of the complete fracture care service. Determining the correct coding in these ‘plot twist’ scenarios depends heavily on who performs what service and where it is performed. It’s critical to remember that Medicare, and many other payers, consider all providers within the same group practice as a single entity for billing purposes. This has significant implications for fracture care coding scenarios, especially when different providers within the same group handle different phases of care. While taxonomy codes can sometimes differentiate specialists within a large group, we will focus on the more common scenarios within a unified group practice for this discussion on fracture care coding scenarios.

Plot Twist Example One: Split Responsibility within the Same Group

Scenario: A Physician Assistant (PA) in the Emergency Department performs fracture reduction (manipulation). However, a physician within the same group practice handles all subsequent post-operative care in the clinic setting. How should this fracture care coding scenario be reported?

In this fracture care coding scenario, the PA can report both the initial ED visit (potentially as a consultation, depending on payer rules) and the closed fracture reduction procedure code. The key here is the appropriate use of modifiers. Although global surgery modifiers are traditionally used when different group practices are involved, the nuances of same-group billing, particularly concerning APPs, open up specific coding possibilities.

Remember, payers like CMS treat APPs and physicians within the same group as a single provider. From a strict payer perspective, using global modifiers within the same group might seem unconventional. However, considering the practicalities of revenue distribution and accurate service attribution within a group, exploring the use of modifiers becomes relevant. It’s also essential to consider the site of service differential – services in the office/clinic (POS 11) are reimbursed at a higher rate than in the Emergency Department (POS 23) due to overhead considerations.

First Consideration: The fracture reduction was performed in the ED (POS 23), while post-operative care occurs in the office (POS 11), billed by a different provider within the same group. Using global surgery modifiers becomes a mechanism to potentially unbundle the global surgical package for internal accounting and potentially optimized reimbursement that reflects the different cost structures of each setting. Without modifiers, the post-operative management RVUs (relative value units), which account for a significant portion of the global package (21% wRVU for -55 modifier), would be inherently bundled into the PA’s reduction code, reimbursed at the PA rate (85% of the Physician Fee Schedule).

Second Consideration: Physician reimbursement under the Physician Fee Schedule (100% MPFS) is inherently higher than the reimbursement for a PA (85% MPFS). In scenarios where a physician provides the post-operative care, utilizing modifiers can ensure that the portion of care they deliver is recognized at the physician reimbursement rate, reflecting their level of expertise and responsibility in the fracture care coding scenario.

Third Consideration: Ethical and accurate coding dictates that billing should always precisely reflect where and when services were rendered and who delivered the care. While payers view the group as a single entity, internal tracking and potentially optimized billing strategies might necessitate modifier usage to delineate service components within the group, even if primarily for internal accounting and revenue distribution.

CPT Procedure Modifiers Relevant to Fracture Care Coding Scenarios:

-54 Modifier: Surgical Care Only (Approximately 69% of the global surgery wRVU) – To be used when the provider performs the surgical procedure but not the pre- or post-operative management.
-55 Modifier: Post-Operative Care Only (Approximately 21% of the global surgery wRVU) – Used when the provider furnishes only the post-operative management and not the surgical procedure.
-56 Modifier: Pre-Operative Care Only (Approximately 10% of the global surgery wRVU) – For when the provider performs only the pre-operative care and not the surgical procedure or post-operative management.
-57 Modifier: Decision for Surgery (For Evaluation and Management Services within a 90-Day Global Period) – Appended to an E/M code to indicate the encounter was where the decision for a major surgery (90-day global) was made.

Plot Twist Example Two: Stabilization vs. Definitive Treatment in the ED

Scenario: A PA in the emergency room evaluates a patient with a fracture and applies a cast or splint for stabilization only. The patient is then scheduled for follow-up with an Orthopedic Surgeon in the office. In this fracture care coding scenario, the PA does not perform a fracture reduction in the ED.

In this scenario, it is entirely appropriate for the PA to report an E/M service code (e.g., for a consultation or initial ED visit) along with a code for the application of the cast or splint. Since no manipulation (reduction) was performed by the PA in the ED, a closed fracture care code with manipulation is not appropriate. The orthopedic surgeon, upon seeing the patient in the office, will then determine the definitive treatment plan. Based on their evaluation, the orthopedic surgeon will decide whether to proceed with closed fracture care with manipulation (and report the appropriate fracture care code) or continue with conservative management and potentially report subsequent E/M services as needed. The key differentiator in this fracture care coding scenario is the absence of manipulation by the PA in the ED.

Conclusion: Case-by-Case Consideration in Fracture Care Coding Scenarios

In summary, accurately coding fracture care, particularly when manipulation is involved, requires a careful, case-by-case approach. Understanding the definitions of restorative and definitive care, the roles of different providers, and the appropriate use of modifiers is paramount. While these examples provide guidance, always consider the specific details of each patient encounter and consult authoritative resources to ensure compliant and accurate fracture care coding in every scenario.