Help physicians and patients understand exactly what it all means.
One of the most asked questions coders get from patients at an orthopedic practice is: “Why is there a surgical code on my bill for an office visit?” It’s a valid question coming from a patient who was seen in the clinic, treated for a fracture, then later received their explanation of benefits (EOB) statement with a surgical procedure costing around $1,000.
To help providers and patients understand fracture care global billing, let’s review the correct process for coding, provider documentation tips, and information you can provide patients regarding why they are billed such a high-cost code for a clinic visit.
Options for Fracture Care Coding – Office Visits
A patient arrives at the clinic with an injury that is evaluated and X-rayed. The provider discusses the treatment options appropriate for the level of severity. If the fracture is severe enough, the patient might have to be scheduled for surgery; however, if the fracture is minor and can be treated non-surgically in the clinic, the provider has two options for reporting this patient’s visit. The options are shown in Table A.
Table A: Fracture Care Coding options for nonsurgical fracture care
|Global Fracture Care||Non-global Fracture Care|
|Closed treatment code (includes casting)||Casting CPT® (initial +2)|
|Follow-up Visits Post Global
|Follow-up Visits Post Non-global Fracture Care|
|Casting CPT® (2 casts) using modifier 58||Approx. 1-3 more visits|
If the provider chooses to bill a global code for the initial procedure, then they can bill for the initial evaluation and management (E/M), casting supplies, and X-rays. Any visit after this will be a post-op visit, and the casting with modifier 58, supplies, and X-ray will be billable.
If the provider chooses to bill non-global, then the E/M, casting, casting supplies, and X-rays are billed for the initial visit and all subsequent visits.
The first cast is inclusive to the global surgical CPT® code, but re-applications are billable. If a reduction of the fracture is done in the clinic, then it would be appropriate to use the closed treatment global code with or without manipulation.
Proper Documentation for Fracture Care Is Key
To support a global fracture care CPT® code, the provider must document that the patient received “definitive fracture care.” This is where it can get confusing.
If your provider chooses to bill a closed treatment fracture care code, ask yourself the following questions:
- Did the provider put a plan into place for follow-up treatment?
- Was an immobilization device provided?
- Was medication/pain management provided?
If the answer to any of these questions is yes, the closed treatment code is billable for fracture care management.
Important: When billing a closed treatment code, do not code the cast/splint application. You cannot bill the patient for both.
Work with your clinic management staff to create a policy for fracture care coding, and make sure everyone understands the policy — including the patient. You do not want an upset patient contacting the billing department asking why a surgery charge is on their clinic bill. If the patient is made aware ahead of time that the charge will encompass casting/splint for that day, as well as subsequent office visits within the global period, you have reduced the chances for any billing surprises.