Coding for fracture care in the emergency department (ED) presents unique challenges for medical coders. Understanding the nuances of billing for these services is crucial for accurate and compliant medical billing. This guide breaks down the essential aspects of emergency fracture care coding, ensuring you navigate the complexities with confidence.
Understanding Fracture Care Types in the ED
In the emergency department setting, fracture care generally falls into two distinct categories: definitive care and restorative care. Differentiating between these types is the first step to accurate coding and billing.
Definitive Fracture Care: Stabilization and Pain Management
Definitive care, also known as non-manipulative care, focuses on providing immediate pain relief and stabilizing the fracture to prevent further injury. This type of care is typically employed for fractures that are non-displaced or minimally displaced, often involving smaller bones. In definitive care, the physician immobilizes the fracture using methods like splinting or buddy taping.
Examples of Definitive Care in the ED:
- Phalangeal Fracture: Treating a finger fracture by applying a splint or buddy taping to immobilize and support the injured digit.
- Stable Rib Fracture: Managing a non-displaced rib fracture with taping and respiratory therapy to alleviate pain and encourage proper breathing, avoiding restrictive devices.
- Nasal Fracture: Addressing a nasal fracture with ice packs and pain medication to reduce swelling and discomfort.
For definitive care, coders should utilize CPT® codes that specify “Closed treatment of [XYZ] fracture without manipulation.”
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 that coding guidelines can evolve. For instance, while code 21800 (Closed treatment of rib fracture, uncomplicated, each) was previously used, it has been deleted. Current guidelines, as per the CPT® 2015 codebook, direct coders to use Evaluation and Management (E/M) codes for reporting closed treatment of uncomplicated rib fractures.
Restorative Fracture Care: Manipulation for Alignment
Restorative care, conversely, involves manipulative care aimed at restoring a displaced fracture to its correct anatomical alignment. This is necessary when the bone fragments have shifted out of position. Physicians employ various manipulative techniques—including traction, flexion, extension, and rotation—to reposition the bone fragments before immobilizing the area with a cast or splint. If the manipulation is unsuccessful in achieving anatomical alignment, the patient typically requires referral to a specialist for more advanced intervention.
Restorative care is reported using CPT® codes that specify “Closed treatment of [XYZ] fracture with manipulation.”
CPT® Code Examples for Restorative Fracture Care:
- 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 ED Fracture Care Services
A critical aspect of emergency department fracture care coding is determining which provider is entitled to bill for the fracture care services. Generally, the ED physician can bill for fracture care when they provide a level of treatment comparable to that of a specialist, such as an orthopedist. However, specific scenarios dictate who should bill for the services rendered.
Scenario 1: Orthopedic Specialist Provides Fracture Care in the ED
If an orthopedic physician is called to the emergency department to manage a fracture, the orthopedic physician, not the ED physician, is the provider who should report and bill for the fracture care.
Scenario 2: Definitive Care in ED Followed by Specialist Referral (Global Care by Specialist)
When a patient receives definitive fracture care in the ED and is then referred to an orthopedic specialist for follow-up within a short timeframe (typically three to five days), the global fracture care billing rights usually transfer to the specialist. This is because the specialist assumes responsibility for the comprehensive fracture treatment and ongoing care.
Example: A patient presents to the ED with a distal radius fracture. The ED physician applies a splint and advises the patient to follow up with an orthopedist immediately. In this case, the ED physician bills for the splint application (29125 Application of short arm splint (forearm to hand); static), while the orthopedic physician bills for the fracture care itself because they will provide the subsequent and complete fracture management.
Scenario 3: Definitive Care in ED with Follow-up Referral (ED Bills for Fracture Care)
Conversely, if the ED physician provides definitive care and refers the patient for follow-up with a specialist within a similar timeframe, but the ED physician is considered to have provided the complete fracture treatment at the emergency level, then the ED provider can bill for the fracture care. The follow-up in this scenario is considered for the next level of care or ongoing management of the fracture.
Example: A patient with a distal radius fracture receives a splint application in the ED, and the ED physician advises follow-up with an orthopedist within three to five days. In this instance, the ED physician can report the fracture care code (25600 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) with modifier 54 (Surgical care only) appended to indicate that only the surgical (fracture treatment) component of care is being billed, and not the global care.
Key Points for Accurate ED Fracture Care Coding
To ensure accurate and compliant coding for fracture care in the emergency department, remember these essential points:
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Global Fracture Care Definition: “Global fracture care” encompasses the complete treatment of a fracture, including the initial fracture care, any necessary restorative care, and all routine follow-up care until the fracture is considered healed. The provider billing for global care assumes responsibility for all these components.
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Restorative Care Requirement for Fracture Code Billing: To bill using a specific fracture care code (rather than just an E/M code), the treatment provided must meet the criteria for “restorative” care, which involves more than simply applying a splint after initial assessment. It implies active treatment aimed at fracture stabilization and management. Physicians who provide a significant portion of global fracture care are eligible to bill the appropriate CPT® code for the fracture treatment, encompassing the global surgical package.
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ED Physician Billing with Modifier 54: Emergency department physicians (and qualified non-physician practitioners authorized to provide ED services) who deliver fracture treatment that meets the restorative care definition but do not provide ongoing follow-up care should report the fracture treatment code with CPT® modifier 54. This modifier signals that the ED provider is billing for the surgical care portion of the fracture management only.
Example: A patient in the ED has a displaced metacarpal fracture. The ED physician performs manipulation to reduce and realign the fracture and then applies a splint. This scenario should be coded as 26605-54, reflecting the closed treatment with manipulation and the surgical care only modifier.
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Non-ED Physician Billing with Modifier 55: A non-ED physician, such as an orthopedic surgeon, who takes over the follow-up care, including casting, ongoing evaluation and management, and treats the patient until the fracture heals, can bill for the fracture treatment code with CPT® modifier 55 (Postoperative management only). This modifier indicates that the physician is billing for the postoperative management component of the global fracture care.
Example: A patient receives initial fracture treatment in the ED. Subsequently, the patient follows up with an orthopedist who applies casting or splinting and manages the patient until fracture healing. In this case, the ED physician would report 26600-54 (Closed treatment of metacarpal fracture, single; without manipulation, each bone-54), and the orthopedist would report 26600-55, reflecting the split billing of surgical care and postoperative management.
Source: Adapted from CGS Medicare, “Billing for Fracture Care: Emergency Department vs. Physician/Orthopedic Office,” www.cgsmedicare.com/partb/pubs/news/2013/0513/cope22035.html
Disclaimer: Coding guidelines and payer policies are subject to change. Always refer to the most current coding manuals and payer-specific guidelines for accurate and up-to-date information.
By understanding these key aspects of emergency department fracture care coding, healthcare providers and coding professionals can ensure accurate billing and reimbursement for the critical services provided to patients with fractures in the ED setting.
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