Fracture care coding in the emergency department (ED) can present complexities that require a nuanced understanding. For those working in medical billing and coding, particularly within facilities like carcodescanner.store which deals with automotive injury related billing, grasping the essentials of ED fracture care is crucial for accurate claims processing and revenue cycle management. This article breaks down the critical aspects of fracture care coding in the ED, ensuring clarity and precision in billing practices.
Definitive Versus Restorative Fracture Care: What’s the Difference?
When it comes to fracture care provided in the ED, it fundamentally falls into two categories: definitive care and restorative care. Distinguishing between these two is the first step in selecting the correct CPT® codes.
Definitive Care (Non-Manipulative)
Definitive care, also known as non-manipulative care, focuses on pain management and stabilization of the fracture. This is typically achieved through immobilization. Fractures that are often treated with definitive care in the ED are those involving small bones, which are either non-displaced or minimally displaced. Long bone fractures without significant displacement can also sometimes fall under this category.
Examples of definitive care include:
- Treating a finger fracture by placing it in a splint or buddy taping it to an adjacent finger.
- Managing a stable, non-displaced rib fracture with taping and breathing exercises, avoiding braces or splints that could restrict breathing.
- Addressing a nasal fracture with ice packing and pain medication.
Definitive care is reported using CPT® codes that specify “Closed treatment of [XYZ] fracture without manipulation.” Here are some CPT® code examples for definitive fracture care:
- 21310 – Closed treatment of nasal bone fracture without manipulation
- 23500 – Closed treatment of clavicular fracture; without manipulation
- 26720 – Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each
- 28510 – Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each
It’s important to note coding updates. For instance, while code 21800 (Closed treatment of rib fracture, uncomplicated, each) was previously used, it was deleted in 2015. Currently, uncomplicated rib fracture treatments are reported using Evaluation and Management (E/M) codes, according to the CPT® 2015 codebook.
Restorative Care (Manipulative)
Restorative care, or manipulative care, is necessary when fractures are displaced. In these cases, manipulation is required to restore the fractured bone to its correct anatomical alignment. Physicians use various manipulative techniques, such as traction, flexion, extension, and rotation, to reposition the bone fragments. Once the bone is properly aligned, the fractured body part is immobilized using a cast or splint. If manipulation fails to restore the bone to its correct position, the patient usually needs to be referred to a specialist for further intervention.
Restorative care is reported with CPT® codes that describe “Closed treatment of [XYZ] fracture with manipulation.” Examples of these codes include:
- 26605 – Closed treatment of metacarpal fracture, single; with manipulation, each bone
- 26725 – Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each
- 27762 – Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction
- 28435 – Closed treatment of talus fracture; with manipulation
- 28515 – Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each
Determining Who Bills for Fracture Care Services in the ED
A crucial aspect of fracture care coding in the ED is understanding who is entitled to bill for the services provided. Typically, an ED physician can bill for fracture care if they provide treatment that is equivalent to what a specialist, like an orthopedist, would offer. However, if an orthopaedic physician is called to the ED to treat the fracture, then it is the orthopedist, not the ED physician, who should report the fracture care.
Consider these scenarios:
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ED Physician Provides Definitive Care and Refers Out: If an ED physician provides definitive care, such as applying a splint for a distal radius fracture, and then refers the patient to an orthopedist for follow-up within a few days, the orthopedist generally bills for the complete fracture care. In this case, the ED physician can bill for the splint application (e.g., 29125 for a short arm splint), but the fracture care coding is attributed to the orthopedist who will manage the ongoing treatment.
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ED Physician Provides Complete Fracture Care: Conversely, if the ED physician provides definitive care and the follow-up with a specialist is considered for the next level of care rather than the completion of the initial fracture treatment, the ED physician can bill for the fracture care. For instance, if an ED physician applies a splint for a distal radius fracture and advises follow-up with an orthopedist in three to five days, the ED physician reports the fracture care (e.g., 25600 for closed treatment of distal radial fracture without manipulation) with modifier 54 (Surgical care only).
Key Points to Remember for Fracture Care Coding in the ED
To ensure accurate fracture care coding in the ED, it’s important to keep several points in mind:
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Global Fracture Care: “Global fracture care” encompasses the entire treatment process, including the initial fracture treatment and all necessary follow-up care until the fracture is healed.
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Restorative Care Threshold: To bill for fracture care, the treatment must meet the criteria for “restorative” care and involve more than just splinting after straightening the limb. Simply applying a splint might not qualify as fracture care billing unless manipulation or restorative efforts are involved.
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ED Physician Billing with Modifier 54: ED physicians who provide fracture treatment that is considered more than basic splinting but do not manage the follow-up care should use the appropriate fracture treatment CPT® code with modifier 54. This indicates that they performed the surgical care portion of the global service.
- Example: For a displaced metacarpal fracture manipulated and reduced by the ED physician who then applies a splint, the correct coding would be 26605-54.
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Non-ED Physician Billing with Modifier 55: Specialists like orthopaedic surgeons who take over the follow-up care, including casting, and manage the patient until healing, should use the fracture treatment code with modifier 55 (Postoperative management only).
- Example: If a patient receives initial treatment for a metacarpal fracture in the ED, and then an orthopedist provides casting and follow-up until healed, the ED physician would report 26600-54 (if they provided treatment without manipulation), while the orthopedist would report 26600-55.
Understanding the nuances of fracture care coding in the ED is essential for accurate medical billing. By correctly differentiating between definitive and restorative care, and knowing the rules for who can bill for these services under various scenarios, healthcare providers and billing professionals can ensure compliance and appropriate reimbursement. For further resources and detailed guidelines, refer to resources from CGS Medicare and AAPC for comprehensive insights into emergency department and fracture care billing.
