Recent changes make coding of non-surgical closed fractures without manipulation a challenge.

Given how common fractures are in the orthopedic physician’s office, providers must get clear on these codes to capture the revenue they’ve earned. MedScape’s “Physician Compensation Report 2020” tells us that orthopedic physicians struggle with one of the highest claims denial rates in healthcare: 18%. Orthopedists must lower these denial rates to remain viable.

Not all the denial blame can be laid at the feet of payers. Denials often stem from coding errors made in the orthopedics office. These reminders will clarify the often-confusing coding requirements for fracture care. Share them with your staff to help ensure claims and prior authorizations are submitted correctly the first time.

Choosing Fracture Care vs. Individual Visits

First, there has always been a question as to whether it’s better to report a fracture care code, which is all encompassing in the way a surgery is, or instead to bill for the supplies and application along with individual follow-up visits. Fracture care codes include all supplies, applications and office visits and are reimbursed at a higher rate (like surgeries).

The decision as to whether to use the fracture care code or not stems from the treatment plan. The orthopedic physician’s responsibility is to heal the fracture in the best way possible. That could include services and supplies that are best grouped under the fracture care code. Typically, providers use the fracture care code in cases of severe fractures.

The provider may also decide it makes the most sense to bill for office visits, applications and supplies individually. For instance, a fractured hip that has to heal on its own may only require two office visits and limited supplies. In cases like these, providers often bill for a few office visits. The provider chooses the best outcome without overburdening either the patient or the payer with fees.

Before making a decision to use the fracture care route or not, please note that there must be a clear plan of action documented in the patient progress note for the initial visit, with evidence the patient has been provided follow-up care.

Although non-operative fracture care services do not require surgery, similar to surgery, they carry a 90-day global period. When you bill your in-office fracture care for the initial visit, append modifier 57 to the evaluation and management service. Without this modifier, the visit will be denied as it is included in the global package of the surgery. Here are some tips to ensure proper coding.

Fracture Care Appropriate Diagnosis Selection

Every year on October 1, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics update ICD-10-CM Official Guidelines, changing the code set to include specifics about the type of fracture

These changes mean providers must avoid “unspecified” at all costs. The payer will reject and say they need more details.

ICD-10 fracture coding now allows for greater specificity as to the type of fracture, anatomical site, laterality. Still, billing specialists can get confused when reporting the appropriate seventh digit while treating a fracture. Here are the 3 types of encounters involved in reporting closed fractures.

  • Initial encounter (A) – used while the patient is receiving active treatment for the injury (for example surgical treatment and evaluation/continuing treatment by the same or a different provider).
  • Subsequent encounter (D) – used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing phase.
    • A common mistake made in subsequent encounters is automatically assigning the D digit after the initial visit. You will continue to use the A (initial encounter) digit during active treatment.
  • Sequela (S) – used for complications or conditions that occur as a direct result of an injury, such as scar formation after a burn.

Accurate CPT Coding Considerations

Keep these specifics in mind when coding fracture care:

  • CPT coding guidelines stipulate that the provider must use the fracture care codes designated as “closed treatment without manipulation” and bill the initial E/M with modifier 57.
  • Although closed fracture care services do not require surgery, they carry a 90-day global period. Even if the services are provided in office, and you are billing for the fracture care, a modifier 57 needs to be appended to the evaluation and management code used. Without this modifier, your visit will be denied as included in the global package of the surgery.
  • If the physician providing the initial treatment will not be providing the subsequent treatment, modifier 54 should be appended to indicate surgical care only. Keep in mind that this modifier will reduce reimbursement.

Specific Closed Fracture Considerations

  • If the provider treating the fracture does not plan to provide the subsequent care, only report an evaluation and management code.
  • Closed treatment without manipulation requires the delivery of some sort of supply like casts or splints for immobilization to meet the criteria for reporting a fracture treatment code.

Accurately Coding X-rays In Office

Coding services and supplies aren’t the only place billing specialists make errors. X-rays can also be miscoded, resulting in denials. Keep these points in mind when coding X-rays:

  • If the same provider reads and interprets the same number of pre and post-reduction views, bill two units of the radiology CPT code. Append modifier 76 to the second code.
  • Bill for subsequent x-rays taken in office that are interpreted by the surgeon. These are required to ensure the fracture is healing and alignment has been maintained.
  • Document the number of views along with the interpretation either in a separate report or in a dedicated section within the office note.
  • When reporting x-rays to insurance, apply the appropriate anatomical modifier. For example, make sure to use LT and RT where appropriate. If you miss laterality, the claim will be denied.
  • Keep in mind that payers only consider X-rays and other radiology services valid with a signed order by the treating physician.

Accurate Coding Casts, Splints, And Miscellaneous Supplies

  • If no fracture care code is being billed, providers can bill for the initial cast application and cast supplies. Still, you must only bill for this initial treatment when E/M is billed. When using the fracture care code, the 90-day global period applies, incorporating the initial application and supplies.
  • Casting, splinting, or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment. Most commercial payers make their own determination whether the supply will be paid.

Accurate Fracture Coding Leads To Reliable Revenue

You’ve probably heard Albert Einstein’s quote, “Insanity is doing the same thing over and over and expecting different results.”

Orthopedic practices and departments that have been throwing the same old protocols at an 18% denials rate for years with no improvement must consider changing direction. Our clients enjoy an average 40% reduction in denial rates and many drop their individual denial rates to 1%. These improvements come courtesy of our highly qualified medical coders who maximize your reimbursement while continuously improving your coding workflow.

Request a demo today to see how we can start as your coding back office, improving your revenues while educating your team on coding best practices.