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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."

Reviewed 12.09.2022

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