AAOS Now

Published 9/1/2012
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Mary LeGrand, RN, MA, CCS-P, CPC

Commonly Asked Fracture-Related Coding Questions

This issue of AAOS Now takes a look at some commonly asked fracture-related coding questions.

Using a global fracture CPT code
Q.
The physician saw a patient in the office for a shoulder injury sustained during football training camp activity. Following the evaluation, the physician diagnosed a nondisplaced clavicle fracture. No cast or splint was applied. Can we report a global fracture code?

A. It is acceptable to report the global fracture code 23500 (closed treatment of clavicular fracture; without manipulation) for this service even if a cast or splint is not applied on the initial date. The global fracture code includes the work of the application of the cast or splint when performed, but the absence of such stabilization does not preclude its use.

CPT code 23500 has a 90-day global period, so it includes the work associated with the day the fracture is diagnosed and all follow-up evaluation and management (E&M) services for the next 90 days.

Cast applied by a hospital cast tech
Q.
Our hospital has a special procedure room for fracture patients who are seen in the emergency department. Patients are seen by our physicians or physician assistants (PAs) but the hospital-employed cast technician applies the cast. Can our physicians or PAs report the application of the cast if the service is actually performed by the hospital-employed cast tech?

A. The question seems to indicate that the physicians and physician assistants are part of a private practice providing a service in the hospital facility. The cast tech is not employed by the private practice, but by the hospital. The application of the cast by the hospital-employed cast tech is not reportable by the physician or the PA, even if they supervise the cast application.

Cast change on Medicare patients
Q.
Occasionally, a Medicare patient needs a cast change and comes to the office when the physician or PA is not there. The cast tech calls the doctor and discusses the situation. The physician directs the cast tech to apply a new cast. Can we bill for the cast application in this situation? We have not been doing so, but are wondering if we have been missing an opportunity to report services.

A. Your inclination not to report the service is correct. Medicare allows for incident-to billing only when certain rules are met. This requires a physician or nonphysician practitioner to be in the office (but not necessarily in the cast room). Continue with your current practice of not reporting this service if a supervising provider is not in the office. Although application of the cast is not separately reportable, the supplies, if documented, may be reported.

Fracture manipulation
Q.
On Aug. 10, 2012, the orthopaedic surgeon saw a patient, diagnosed a nondisplaced distal radius fracture, applied a cast, and reported CPT code 25600 (Closed treatment of distal radial fracture [eg, Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation). The surgeon also reported the office visit, cast supplies, and the cast application.

On Aug. 28, the patient returned, complaining of increasing pain. The surgeon re-evaluated the patient, obtained new radiographs, and saw that the alignment of the fracture had changed. He performed a hematoma block, manipulated the fracture, and applied a new cast. Postreduction radiographs showed good alignment. The surgeon wants to report a global code again. Is this the correct coding?

A. Assuming that the documentation supports the work, the scenario described for Aug. 10, 2012, supports reporting the following services:

  • E&M-57 (some payers may want modifier 25)
  • 25600
  • Radiographs (Code selection will be based on documentation of specific views and a separate report for the interpretation.)
  • Cast supplies (Documentation must include the location of the cast, length, type [plaster vs fiberglass (number of rolls)] and other supplies to report the “Q” HCPCS codes or “A” HCPCS codes based on payer requirements.)

The cast application is not separately reportable because it is inclusive to the global fracture service.

Assuming that the documentation supports the work, the services provided on Aug. 28, 2012, are reported as follows:

  • 25605-58 (Closed treatment of distal radial fracture [eg, Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation)
  • Radiographs (Code selection will be based on documentation of specific views, anatomic location, and a separate report for the interpretation.)
  • Radiographs-76 (Code selection will be based on documentation of specific views and a separate report for the interpretation. Modifier 76 indicates a repeat procedure on the same day by the same physician.)
  • Cast supplies (Documentation must include the location of the cast, length, type [plaster vs fiberglass (number of rolls)] and other supplies to report the “Q” HCPCS codes or “A” HCPCS codes based on payer requirements.)

The “slippage” of the fracture is not considered a complication of the original procedure. The fracture displaced, requiring the performance of a more extensive procedure to manage the condition. Modifier 58 is the most appropriate modifier to append to CPT code 25605 to indicate the more extensive procedure related to the nature of the disease process. Modifier 78 should not be used for the following reasons:

  • The change in alignment is not a complication of the original procedure. Although it is related to the original service, the manipulation is required to realign the fracture, so modifier 58 is more appropriate.
  • Modifier 78 may not be reported for a procedure performed in the office setting.
  • Action steps

For proper coding of fracture-related care, take the following steps:

  • Ensure that the documentation supports the decision for nonsurgical management of the fracture to support the global radiology codes. Use a statement such as “Patient presents with a nondisplaced fracture of the distal radius. The fracture does not require surgical manipulation at this time and we will manage the injury nonsurgically or without manipulation.”
  • Conduct an audit of fracture-related services to ensure the documentation requirements are met for reporting cast reapplication during the global period.
  • Make sure that the notes contain specific information to support reporting the appropriate supply codes.
  • Report the “A” HCPCS supply codes for plaster or fiberglass casts for payers that recognize these codes. Report the “Q” HCPCS supply codes for plaster or fiberglass supplies to Medicare and those payers requiring the “Q” codes.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.