Fracture Care Follow Up Coding: A Comprehensive Guide for Orthopedic Practices

Coding for closed treatment of fractures without manipulation can present complexities for medical coders. To ensure accurate reimbursement for services provided, a thorough understanding of fracture classifications, relevant codes, and the scope of work they encompass is essential. Let’s delve into the intricacies of Fracture Care Follow Up Coding, focusing on closed treatment without manipulation.

Understanding the Spectrum of Fracture Treatment

When a patient sustains a traumatic fracture and seeks medical attention, orthopedic physicians typically employ one of four primary treatment approaches:

1. Closed Reduction: This non-surgical technique involves manually manipulating the fractured bone to restore its normal anatomical alignment.
2. Percutaneous Fixation: This procedure entails inserting a stabilizing device, such as wires, pins, screws, rods, or plates, across the fractured bone, often guided by imaging technology.
3. Open Reduction with Internal Fixation (ORIF): ORIF is a surgical intervention that involves making an incision to realign and secure the fractured bone fragments using internal fixation devices.
4. Closed Treatment Without Manipulation: This method involves providing the patient with appropriate medical supplies to stabilize the bone and facilitate weight-bearing or non-weight-bearing function.

The Core of Closed Treatment: Medical Supplies

Closed treatment without manipulation is frequently the least understood among the common fracture care methods. When fracture manipulation is not performed, what constitutes “treatment”? In this context, treatment centers around the provision and application of medical supplies designed to immobilize a joint, allowing fractured bone segments to fuse, or to offer support for weight-bearing activities. These supplies can include casts, splints, slings, braces, canes, walking boots, and crutches.

Crucially, if a healthcare provider does not utilize a medical supply to stabilize the fracture or fails to establish a plan for fracture care follow up, reporting non-operative, non-manipulative fracture care codes is not appropriate. Instead, the provider should code for an Evaluation and Management (E/M) service without a modifier for the initial visit and utilize appropriate E/M service code(s) for subsequent, related encounters.

Example: Consider a 17-year-old female soccer player who slipped on a wet athletic field, sustaining an injury. Three days later, she consults her physician, who diagnoses a nondisplaced left foot cuboid fracture during a level 3 established patient visit. The physician fits her with a custom-fabricated plastic ankle-foot orthosis with an ankle joint and schedules a fracture care follow up appointment in two weeks, or sooner if her pain persists. This scenario exemplifies closed treatment without manipulation. Accurate CPT® coding would include 28450-LT Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each – Left side and 99213-57 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity – Decision for surgery. As the ankle-foot orthosis was provided in the office, it can be billed separately using L1970 Ankle foot orthosis, plastic with ankle joint, custom fabricated.

CPT Codes for Non-operative, Non-manipulative Fracture Care

The following table outlines common fracture sites and their corresponding CPT codes for closed treatment without manipulation:

Documentation Requirements for Accurate Coding

Appropriate documentation is crucial for reporting non-surgical/non-manipulative fracture care. Acceptable documentation should clearly specify the medical supplies provided for immobilization and support.

Conversely, nonspecific documentation that does not justify reporting non-surgical/non-manipulative fracture care includes terms like:

• Activity modification
• Bed rest
• Dressing change only
• Elevation
• Gait/balance training
• Home exercise program
• Ice (with rest, compression, and elevation)
• Medication prescription (such as for pain control)
• Non-operative/nonsurgical treatment with no elaboration
• Non-weight bearing (NWB) with no elaboration
• Physical therapy
• Proprioception
• “Protected” WB
• Walking aid not specified
• Weight bearing as tolerated (WBAT) with no elaboration

Although non-operative, non-manipulative fracture care services are non-surgical, they are assigned a 90-day global period. Consequently, if an E/M service is performed on the same day as fracture care – which is often the case – modifier 57 Decision for surgery must be appended to the E/M code. Subsequent fracture care follow up visits within the global period (91 days, encompassing the treatment day) are tracked using 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.

Billing Strategies: Fracture Care vs. Supply and E/M Coding

A recurring debate exists regarding whether to forgo reporting a fracture care code and instead bill for the supply, its application, and individual fracture care follow up visits until fracture healing. The prevailing consensus favors utilizing fracture care codes designated for “closed treatment without manipulation” and billing the initial E/M service with modifier 57. This approach more accurately reflects the actual work involved in the rendered services, supported by robust documentation.

The optimal fracture care coding strategy may vary on a case-by-case basis, requiring clinical judgment. For instance, some orthopedic physicians suggest that minor digital fractures treated with buddy taping may be more appropriately reported using multiple E/M visits rather than fracture care codes, as the cumulative Relative Value Units (RVUs) for multiple visits might be higher.

Another scenario involves fracture care provided in the emergency room (ER). While some suggest reporting with modifier 54 Surgical care only for the fracture care and modifier 55 Postoperative management only for subsequent office visits to the orthopedic practitioner if the device fitting was done by an ER doctor, this method is questionable. It is questionable because there is no surgical procedure or fracture reduction involved, and post-operative management reimbursement is significantly lower (approximately 20 percent of the allowable charge), potentially undercompensating for the visit RVUs.

When reporting a non-operative, non-manipulative fracture care code, it is imperative to document a clear plan of action in the patient’s progress note for the initial visit, along with evidence of fracture care follow up (99024).

Addressing “Incomplete” Fracture Care Services

In situations where a patient discontinues fracture care follow up due to circumstances like relocation or switching to a new practice, a charge correction might be necessary. In such instances, transitioning from a fracture care code to application codes (29xxx series) and supply codes is appropriate. Coders and billers should collaborate to rectify the charge error, even if the fracture care claim has already been processed and paid.

Understanding Exceptions and Payer Guidelines

It’s crucial for physicians, coders, and billers to recognize that CPT® codes for closed fracture treatment without manipulation represent retainer fees for the physician’s comprehensive patient care throughout the global period. The fracture care code encompasses not just the fitting of an orthotic or medical supply, but also all other services provided within the global period, excluding subsequent fittings of new supplies when applicable.

Patients may express concerns about the perceived high cost of closed treatment services upon receiving explanations of benefits, often due to a misunderstanding of the retainer concept. For example, a patient might inquire about a $1,000 deductible applied for a wrist splint fitting. In such cases, it’s essential to explain that the fee covers not only the splint but also fracture care follow up examinations over a 90-day period, in addition to the cost of the splint itself.

Generally, closed treatment without manipulation necessitates the provision of a medical supply to meet the criteria for reporting a fracture treatment code. However, exceptions exist. In severe cases, such as elderly patients with hip fractures, treatment might involve bed rest, pain management, non-weight-bearing instructions, and potential surgical preparations. Similarly, some fracture scenarios in critically ill patients may only involve palliative care focused on pain control. In ambiguous situations, consulting the patient’s payer to clarify their specific guidelines for reporting closed treatment for the fracture type and location is advisable.

Key Principles for Fracture Care Coding

These ground rules apply to both operative and non-operative fracture care coding:

• Initial fittings of casts, splints, strappings, and other materials are bundled into the global service of fracture care.
• Subsequent fittings or refittings performed post-procedurally or after non-operative fracture treatment can be reported with modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period appended to the CPT® code.
• When fracture care is provided in the doctor’s office (POS 11 Office), materials can be billed separately using an appropriate HCPCS Level II code, subject to payer reimbursement policies.
• In a hospital setting, the facility bills for fracture stabilizing materials.
• Fractures not specified as open (or implied by a skin wound) are classified as closed.
• Fractures not indicated as nondisplaced are considered displaced.
• Additional intraoperative services, such as debridement, bone grafts, or removal of existing hardware, may be bundled into fracture surgeries.

By adhering to these guidelines and maintaining meticulous documentation practices, orthopedic practices can ensure accurate fracture care follow up coding and optimize their revenue cycle.

Ken Camilleis

Ken Camilleis, CPC, CPC-I, COSC, CMRS, CCS-P, is a seasoned medical coding professional and educator with extensive experience in provider education programs and clinical documentation integrity projects. He is actively involved in the medical coding community, serving as the 2022 member development officer for Cape Cod Coders, a local AAPC chapter in Hyannis, Massachusetts.

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Don’t Break Your Fracture Care Revenue Cycle was last modified: April 1st, 2018 by Ken Camilleis