Assist physicians and patients in gaining a precise comprehension of the situation.
At orthopedic practices, coders frequently encounter a common question from patients: “Why does my invoice for an office visit include a surgical code?” This query is entirely reasonable, given that a patient was examined in the clinic, treated for a fracture, and later received an explanation of benefits (EOB) statement reflecting a surgical procedure cost of approximately $1,000. To facilitate the comprehension of fracture care global billing for both healthcare providers and patients, let’s delve into the accurate coding process, provider documentation suggestions, and information that can be imparted to patients to elucidate the rationale behind the substantial billing code associated with a clinic visit.
Options for Coding Fracture Care Visits at the Clinic
When a patient arrives at the clinic with an injury, it undergoes evaluation and X-ray assessment. The provider engages in discussions about suitable treatment options based on the severity level of the fracture. In cases where the fracture is sufficiently severe, scheduling surgery might be necessary. Conversely, if the fracture is minor and can be managed non-surgically within the clinic, the provider has two alternatives for documenting this particular patient encounter.
Table A: Fracture Care Coding options for nonsurgical fracture care
| Global Fracture Care | Non-global Fracture Care |
| 99203-57 | 99203-25 |
| Closed treatment code (includes casting) | Casting CPT® (initial +2) |
| Supplies | Supplies |
| X-rays | X-rays |
| Follow-up Visits Post Global Fracture Care | Follow-up Visits Post Non-global Fracture Care |
| Casting CPT® (2 casts) using modifier 58 | Approx. 1-3 more visits |
| Supplies | 99213 |
| X-rays | Casting/supplies, X-rays |
In the event that the provider opts to utilize a global code for the initial procedure, they are eligible to bill for the initial evaluation and management (E/M) service, as well as for casting supplies and X-rays.
Any subsequent visits following this will be considered post-operative appointments, allowing for billing of casting with modifier 58, supplies, and X-rays. On the other hand, if the provider chooses not to use a global code, charges will encompass the E/M service, casting, casting supplies, and X-rays for both the initial and all subsequent visits.
The initial casting falls within the scope of the comprehensive surgical CPT® code, although charges can be applied for subsequent re-applications. If a fracture reduction is performed within the clinic setting, it is appropriate to employ the closed treatment global code, with or without manipulation.
Accurate Documentation Essential for Fracture Care
The cornerstone of supporting a global fracture care CPT® code lies in the provider’s meticulous documentation of the patient’s receipt of “definitive fracture care.” However, this is where the process can become perplexing. In scenarios where your provider selects to utilize a closed treatment fracture care code, it’s prudent to consider the following inquiries:
- Did the provider establish a follow-up treatment plan?
- Was an immobilization device supplied?
- Was medication or pain management administered?
If any of these questions are answered affirmatively, the closed treatment code becomes applicable for fracture care management. Significantly, refrain from coding the cast or splint application when billing a closed treatment code. Dual billing to the patient for both services is not permissible. Collaborating with your clinic’s management team to devise a coding policy for fracture care is imperative. It’s crucial to ensure that everyone comprehends this policy, including the patient. Preventing the occurrence of an irate patient reaching out to the billing department to question a surgical charge on their clinic invoice is paramount. By informing the patient in advance that the charge covers the cast or splint on the specific day, along with subsequent clinic visits encompassed by the global period, the potential for billing-related surprises is considerably diminished.
