Orthopaedic surgeons and patients are becoming more aware that those who sustain a fragility fracture are at significantly higher risk of a future fracture. Although orthopaedic surgeons may not be able to prevent the first fracture, they are increasingly being seen as key in identifying patients at risk for additional fractures. Orthopaedic surgeons are also increasingly being held responsible for either addressing the underlying osteoporosis or referring the patient for osteoporosis management.
Despite the misconception that payment isn’t available for osteoporosis care and management, orthopaedic surgeons can be reimbursed for doing the right thing by supporting patients who have sustained an osteoporotic fracture. In addition, a physician assistant, nurse practitioner, or other allied healthcare professional in the orthopaedic practice can be reimbursed for his or her efforts in ensuring that postfracture osteoporosis patients follow the simple steps needed to help reduce their risk of future fractures.
The fracture liaison service
Implementing a fracture liaison service (FLS) model of care is a tested, effective way to both improve patient outcomes and decrease healthcare costs. An FLS is a coordinated, preventive care model that operates under the supervision of orthopaedists and other bone health specialists and collaborates with the patient’s primary care physician.
FLS programs coordinate postfracture care through an allied health professional—an FLS coordinator—who ensures that patients who have sustained fractures receive appropriate diagnosis, treatment, and support. FLS programs have been successful in a number of settings in the United States (such as through the Kaiser Permanente and Geisinger Health Systems) and abroad (most notably in the United Kingdom and Canada).
FLS programs have been shown to prevent one hip fracture for every 100 patients participating. Thus the economic argument to implement an FLS program is clear.
Despite the success of FLS programs, the lack of adequate reimbursement for the FLS allied health professional coordinators has been a significant barrier to widespread adoption of this model of care in the United States. This article provides guidance on how to bill and code for this service.
Don’t wait until 2014
Unfortunately, coding and reimbursement for FLS care remains underdeveloped. Starting in 2014, specific CPT codes for care coordination services go into effect that would fit the FLS model of care well. But orthopaedic practices shouldn’t put off establishing an FLS program until these codes go into effect.
In 2013, the most appropriate coding is to use established patient Evaluation and Management codes (CPT codes 99211–99215) with a 24 modifier if the patient visit is within the global period of a separate surgical procedure. If the physician is providing consultation services for another provider, the established patient consultation codes (CPT codes 99241–99245 and 99251–99255) can be used. (Note: Medicare does not recognize the consultation codes, but other payers do.)
Also in 2013, the new “transition of care” CPT codes (99495 and 99496) can be used by a physician who is providing the fracture care coordination in non–face-to-face encounters immediately subsequent to a patient’s being discharged from the hospital setting by another physician. These codes apply to services occurring within 14 days of discharge.
Using these codes after a consultation will allow a patient to be referred to a nurse practitioner or other allied healthcare professional for follow-up, management, and monitoring of his or her diagnosed osteoporosis or low bone mass. This intervention is a proven method to help prevent future fractures.
“Own the Bone”
To help support this work, orthopaedists can also consider becoming part of the American Orthopaedic Association’s (AOA) Own the Bone program (www.ownthebone.org), a voluntary FLS program designed to address the osteoporosis treatment gap and prevent subsequent fractures. Own the Bone has been implemented by more than 100 teaching hospitals, community hospitals, medical centers, and private practice groups and has changed clinician behavior and improved patient treatment and referral.
More information about the FLS model of care can be obtained through the AOA (www.aoassn.org) or the National Bone Health Alliance (www.nbha.org), a public-private partnership on bone health. The AAOS is a member of the NBHA.
Mr. Lee is the director of the National Bone Health Alliance. Dr. Filler is an orthopaedic surgeon in Los Angeles, a member of the AAOS Coding, Coverage, and Reimbursement Committee, and the AOA CPT Editorial Panel advisor. Mr. Twetten is the AAOS senior manager of regulatory, quality and medical affairs.
Did you know…?
- Osteoporosis and low bone mass affect more than 40 million American men and women.
- Osteoporosis is characterized by weakened and fragile bone tissue and can lead to an increased risk of fracture.
- Osteoporosis-related fractures are responsible for significant human and financial costs, with 2 million fractures occurring annually.
- The annual costs of osteoporosis to the Medicare system are $22 billion.
- Only 21 percent of women age 67 or older who have an osteoporosis-related fracture had either a bone mineral density test or a prescription for a drug to treat or prevent osteoporosis in the 6 months after the fracture, despite the availability of cost-effective and well-tolerated treatments.