Date:May 3, 2010
Subject:Fracture Care Documentation and Coding - Update
From:EPBS Coding Policy and Advisory Committee
To:EPBS Emergency Medicine and Urgent Care Client
Fracture care is an area with pitfalls for correct emergency medicine and urgent care coding and billing. In order to code for fracture care, the physician must either manipulate the fractured bones (restorative care) or provide the definitive care for the fracture. In cases where the physician does the reduction, coding is straightforward. For non-manipulated fractures, definitive care may include ice, elevation, pain management, anti-inflammatory meds, immobilization via a splint or cast, etc. To code for fracture care of non-manipulated fractures, the majority of the definitive care must be provided in the ED/urgent care by the physician.
The care by the emergency or urgent care physician of the following non-manipulated fractures is generally considered definitive care and reportable. There can be local differences in the reporting of fracture care provided by physicians based on group practice and the availability of orthopedic/specialty care. Please review the list for your practice. If there are any fracture care codes listed where the care by your physicians is generally considered to be stabilization and majority of the definitive care is not provided by your physicians, please inform your client representative. We will remove the codes from the list of reportable services for your practice. Otherwise the fracture care listed will be coded for all charts received May 17 forward.
CPT / FRACTURE CARE DESCRIPTIONS21310 / FRACTURE, NASAL BONE, CLOSED TREATMENT, W/O MANIPULATION
21800-54 / FRACTURE, RIB, CLOSED TRT, UNCOMPLICATED, EACH
21820-54 / FRACTURE, STERNUM, CLOSED TRT
23500-54 / FRACTURE, CLAVICULAR, CLOSED TRT, WITHOUT MANIPULATION
23520-54 / DISLOCATION, STERNOCLAVICULAR, CLOSED TRT, W/O MANIPULATION
23540-54 / DISLOCATION, ACROMIOCLAVICULAR, CLOSED TRT, W/O MANIPULATION
23570-54 / FRACTURE, SCAPULAR, CLOSED TRT, WITHOUT MANIPULATION
23600-54 / FRACTURE, HUMERAL-PROXIMAL NECK (SURGICAL OR ANATOMICAL NECK), …...CLOSED TRT, WITHOUT MANIPULATION
23620-54 / FRACTURE, GREATER HUMERAL TUBEROSITY, CLOSED TRT, …….WITHOUT MANIPULATION
24650-54 / FRACTURE, RADIAL NECK OR HEAD, CLOSED TRT, W/O MANIPULATION
25650-54 / FRACTURE, ULNAR STYLOID, CLOSED TREATMENT
26600-54 / FRACTURE, METACARPAL, (eg Boxer), CLOSED TRT, W/O MANIPULATION, …...EACH BONE
26720-54 / FRACTURE, FINGER OR THUMB, PHALANGEAL SHAFT, PROXIMAL OR MIDDLE …...PHALANX, CLOSED TRT, WITHOUT MANIPULATION, EACH
26750-54 / FRACTURE, FINGER OR THUMB, DISTAL PHALANGEAL, CLOSED TRT, …...WITHOUT MANIPULATION, EACH
27200-54 / FRACTURE, COCCYX (COCCYGEAL), CLOSED TREATMENT
27780-54 / FRACTURE, FIBULA-PROXIMAL OR SHAFT, CLOSED TRT, W/O MANIP
28490-54 / FRACTURE, GREAT TOE, PHALANX OR PHALANGES, CLOSED TRT, …….WITHOUT MANIPULATION
28510-54 / FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, …....CLOSED TRT, W/O MANIPULATION, EACH
28530-54 / FRACTURE, SESAMOID BONE, CLOSED TREATMENT
27786-54 / FRACTURE, FIBULA-DISTAL (e.g., Lateral Malleolus), CLSD TRT, W/O MANIP
If your physicians provide the majority of the definitive care for any non-manipulated fractures that are not listed, the physicians must clearly document “definitive care” in order for the coder to know the service is reportable.
When coding for fracture care, the CPT codes include a “global period” for the fracture; this means that all care required for the fracture during the global period are included in the code. Because emergency physicians and urgent care physicians don’t usually provide follow-up care, a -54 modifier is applied to the code which signifies the physician is providing the majority of the fracture care but not the follow-up care.
The application of an immobilization device is included in the fracture care service. If the fracture care does not include manipulation (restorative care) or is not definitive care, the care in the ED is considered stabilization and only an E&M service and a splint/cast application are reportable.
In review, the coding of fracture care will occur as follows:
Fracture is manipulated/reduced by the emergency/urgent care physician, fracture care will be coded provided documentation is adequate to report the code.
Fracture is not manipulated by the emergency/urgent care physician and the fracture care code appears on the list, fracture care will be coded provided documentation is adequate to report the code.
Fracture is not manipulated by the emergency/urgent physician and the fracture care code does NOT appear on the list, fracture care will not be coded UNLESS the physician specifically states the fracture care was “definitive care” and documentation is adequate to report the code. Otherwise only an E&M service and the application of a splint or cast will be coded.
Adequate documentation for fracture care coding of a non-manipulated fracture would typically include:
Site of the fracture (via exam and/or x-ray results)
Stabilization & support by splinting, strapping or casting (except for fingers, toes, nose, ribs, clavicle, sternum, and coccyx which do not generally require stabilization)
And at least one of the following:
oPain relief
oInstructions for aftercare
oPatient education for the fracture
oFollow-up instructions
As in all aspects of coding, clear and accurate documentation is essential. Again, we acknowledge there can be local differences in the reporting of fracture care provided by physicians based on group practice and the availability of orthopedic/specialty care. Please contact your client representative for questions.