Coding for closed treatment of fractures is nuanced and complex, which can lead to confusion. This article clarifies previously published guidelines on how to code for this form of treatment.
Any physician or qualified health care provider may consider the following methods of coding for closed treatment of a fracture under Current Procedural Terminology (CPT) codes:
- Global: The physician reports the services by using the 90-day global fracture treatment code, with or without an evaluation and management (E&M) service that resulted in the decision for closed treatment and/or was related to a separate injury or separate diagnosis.
- Itemized: The physician reports each service independently using E&M codes and cast/splint codes, but does not enter into a 90-day global period.
The reason for using different methods to code for the closed treatment of fractures may seem counterintuitive to typical CPT approaches. These codes were created more than 20 years ago to allow for global reporting of more than one injury, when at least one other injury is concurrently treated surgically. For example, closed treatment of a fracture may be provided during the global period of an anterior cruciate ligament repair, when both injuries occurred at the same time. Itemized E&M reporting for nonsurgical closed treatment of the fracture often caused confusion with payers when used during the 90-day postoperative global period related to the surgically treated injury. This confusion results in claim denials for the fracture-related E&M services even when the appropriate modifier is appended to the service.
Using global codes for the treatment of all injuries sustained from a traumatic event provides consistency and clarity in terms of reporting physician services and minimizes the administrative costs to both payers and physician practices. Global fracture treatment codes may also be applicable for isolated injuries.
"Restorative treatment" and follow-up care
The two keys to understanding the appropriate coding for closed treatment of fractures is to first determine whether the physician provides "restorative treatment" of the fracture; second, determine whether the same physician will be providing all the follow-up care within the 90-day global period. Restorative treatment is more than simply realigning the limb and applying a splint or cast; rather, it entails a closed reduction by the application of manually applied forces. This closed reduction must achieve satisfactory alignment of the fracture or dislocation—ie, closed reduction must be acceptable for healing and restoration of limb function.
If the physician is providing restorative care of the fracture (eg, closed treatment with manipulation) and all follow-up management, the physician should report the service with the global fracture care code. If the physician is providing restorative care but not providing the follow-up care, the physician should report the encounter using the appropriate global fracture treatment code and add modifier -54 to indicate that only the intraservice work has been provided. With this approach, it is preferred that the initial treating physician inform the physician who will be providing follow-up care regarding how the service was reported (ie, provide the date of service and CPT code(s) and modifier(s)) so that the same CPT code(s) may be reported by the subsequent physician with a -55 modifier (postoperative management only) for the subsequent evaluation during the remainder of the global period.
Closed treatment of a fracture without manipulation is commonly provided by orthopaedic surgeons in many different sites of service (eg, inpatient, outpatient, office, or emergency department [ED]). Typically, orthopaedic surgeons provide follow-up care until fracture healing has occurred and function has been restored. Under these circumstances, the physician can use either the global method or itemized E&M services.
However, if a physician treats a patient for a fracture that does not require restorative care and there are no planned postservice follow-up visits by the same physician, the physician should NOT bill for global fracture treatment; instead, he or she should use the appropriate E&M code and a casting or splinting code, if casting or splinting is provided.
The initial closed treatment of fractures is also provided at times in the ED by emergency physicians or other qualified healthcare providers. Physicians in these settings are unlikely to be responsible for any ongoing follow-up care after initial treatment. Thus, if fracture care that meets the definition of "restorative treatment" is provided by the emergency physician, it is acceptable to use the global fracture care code with modifier -54 (surgical care only). However, if the emergency physician does not provide restorative care, the correct and only method of reporting this service would be to use an ED E&M code, as well as the code for application of a cast or splint, if applied. The global fracture code should not be reported.
William R. Creevy, MD, is a member of the AAOS Coding, Coverage, and Reimbursement Committee. M. Bradford Henley, MD, MBA, FACS, is treasurer on the AAOS Board of Directors, chair of the AAOS Finance Committee, and liaison to the AAOS Current Procedural Terminology Editorial Panel. Margaret M. Maley, BSN, MS, is a consultant with KarenZupko & Associates.