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May 1, 2013

Billing for Fracture Care: Emergency Department vs. Physician/Orthopedic Office

The purpose of this article is to clarify claim submission guidelines for "global" fracture care services and provide clarification on submitting claims for split care (between an Emergency Department (ED) physician and another physician, such as an orthopedist) and splinting and cast application.

Current Procedural Terminology (CPT) manuals suggest that the provider who performs "restorative" treatment is "responsible for the initial cast, follow-up evaluation(s) and the management of the fracture until healed" should use the procedure code which supports the code. The CPT manual continues with definitions of "closed treatment," "open treatment," and "percutaneous skeletal fixation." Closed treatment specifically means that the fracture site is not surgically opened. Closed fracture situations are treated 1) with manipulation; 2) or without manipulation; 3) with or without traction (see the current year CPT manual for additional information).

In general:

  • "Global fracture care" includes treating the fracture and providing any necessary follow-up care ("performing and accepting the care of restorative and follow up treatment of the fracture until healed").
  • In order to submit a claim for fracture care, the treatment must meet the definition of "restorative" care and must involve more than merely splinting the fracture after straightening the limb.
  • Physicians that treat a fracture and provide a "significant portion of the global fracture care" may submit the appropriate CPT code for treating the fracture and be reimbursed for the global surgical package of care.
  • Emergency Department (ED) physicians (and nonphysician practitioners (NPPs) authorized to provide emergency room services) that treat the fracture (as described in the second bullet above) but do not provide follow-up care may submit a claim for the fracture treatment code with CPT modifier 54 (surgical care only).
  • A non-ED physician, such as an orthopedic surgeon, who provides casting, follow-up evaluation(s) and management of the fracture until healed, may submit a claim for the fracture treatment code with CPT modifier 55 (follow-up care only).

Splint and Cast Application

According to CPT, reporting the services using an Evaluation & Management (E/M) code and the appropriate cast/splint application code (as applicable) is supported by the following statement: "If cast application or strapping is provided as an initial service (e.g., casting of a sprained ankle or knee) in which no other procedure or treatment (e.g., surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code in addition to an evaluation and management code as appropriate."

The following codes may be submitted by NPPs for fracture treatment:

21310 Closed tx nose fx w/o manj
21315 Closed tx nose fx w/o stablj
21320 Closed tx nose fx w/ stablj
21337 Closed tx septal&nose fx
21400 Closed tx orbit w/o manipulj
21401 Closed tx orbit w/ manipulj
21440 Treat dental ridge fracture
21450 Treat lower jaw fracture
21451 Treat lower jaw fracture
21480 Reset dislocated jaw
21800 Treatment of rib fracture
21820 Treat sternum fracture
22305 Closed tx spine process fx
22310 Closed tx vert fx w/o manj
23500 Closed treatment of clavicular fracture; without manipulation
23505 Treat clavicle fracture
23520 Treat clavicle dislocation
23525 Treat clavicle dislocation; with manipulation
23540 Treat clavicle dislocation; without manipulation
23545 Treat clavicle dislocation; with manipulation
23570 Treat shoulder blade fx
23575 Treat shoulder blade fx
23600 Treat humerus fracture
23605 Treat humerus fracture
23620 Treat humerus fracture
23625 Treat humerus fracture
23650 Treat shoulder dislocation
23675 Treat dislocation/fracture
24500 Treat humerus fracture, without manipulation
24505 Treat humerus fracture
24530 Treat humerus fracture
24535 Treat humerus fracture
24560 Treat humerus fracture
24565 Treat humerus fracture
24575 Treat humerus fracture
24576 Treat humerus fracture
24577 Treat humerus fracture
24620 Treat elbow fracture
24640 Treat elbow dislocation
24650 Treat radius fracture
24655 Treat radius fracture
24670 Treat ulnar fracture
24675 Treat ulnar fracture
25500 Treat fracture of radius
25505 Treat fracture of radius
25520 Treat fracture of radius
25530 Treat fracture of ulna
25535 Treat fracture of ulna
25560 Treat fracture radius & ulna
25565 Treat fracture radius & ulna
25600 Treat fracture radius/ulna
25605 Treat fracture radius/ulna
25622 Treat wrist bone fracture
25624 Treat wrist bone fracture
25630 Treat wrist bone fracture
25635 Treat wrist bone fracture
25650 Treat wrist bone fracture
25660 Treat wrist dislocation
25675 Treat wrist dislocation
25680 Treat wrist fracture
25685 Treat wrist fracture
25690 Treat wrist dislocation
26600 Treat metacarpal fracture
26605 Treat metacarpal fracture
26607 Treat metacarpal fracture
26641 Treat thumb dislocation
26645 Treat thumb fracture
26670 Treat hand dislocation
26700 Treat knuckle dislocation
26720 Treat finger fracture each
26725 Treat finger fracture each
26740 Treat finger fracture each
26742 Treat finger fracture each
26750 Treat finger fracture each
26755 Treat finger fracture each
26770 Treat finger dislocation
27193 Treat pelvic ring fracture
27194 Treat pelvic ring fracture
27200 Closed treatment of coccygeal fracture
27220 Treat hip socket fracture
27222 Treat hip socket fracture
27230 Treat thigh fracture
27232 Treat thigh fracture
27500 Treatment of thigh fracture
27501 Treatment of thigh fracture
27503 Treatment of thigh fracture
27508 Treatment of thigh fracture
27510 Treatment of thigh fracture
27516 Treat thigh fx growth plate
27517 Treat thigh fx growth plate
27520 Treat kneecap fracture
27530 Treat knee fracture
27532 Treat knee fracture
27538 Treat knee fracture(s)
27550 Treat knee dislocation
27560 Treat kneecap dislocation
27750 Treatment of tibia fracture
27752 Treatment of tibia fracture
27760 Cltx medial ankle fx
27762 Cltx med ankle fx w/mnpj
27767 Cltx post ankle fx
27768 Cltx post ankle fx w/mnpj
27780 Treatment of fibula fracture
27781 Treatment of fibula fracture
27786 Treatment of ankle fracture
27788 Treatment of ankle fracture
27808 Treatment of ankle fracture
27810 Treatment of ankle fracture
27816 Treatment of ankle fracture
27818 Treatment of ankle fracture
27824 Treat lower leg fracture
27830 Treat lower leg dislocation
27840 Treat ankle dislocation
28400 Treatment of heel fracture
28405 Treatment of heel fracture
28430 Treatment of ankle fracture
28435 Treatment of ankle fracture
28470 Treat metatarsal fracture
28475 Treat metatarsal fracture
28476 Treat metatarsal fracture
28490 Treat big toe fracture
28495 Treat big toe fracture
28496 Treat big toe fracture
28510 Treatment of toe fracture
28515 Treatment of toe fracture
28530 Treat sesamoid bone fracture
28540 Treat foot dislocation
28570 Treat foot dislocation
28600 Treat foot dislocation
28630 Treat toe dislocation
8660 Treat toe dislocation

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