Orthopedic FAQ

FAQ 1:  When is it appropriate for an emergency physician to utilize fracture/dislocation (F/D) care codes? Does ED care and/or follow up care need to be "restorative" in order to apply these codes? When should the -54 modifier be used in conjunction with F/D codes when describing ED based care?

Fracture /dislocation (F/D) codes are surgical "global care" procedures. Use of these codes is only appropriate if the emergency physician provides "a significant portion of the global fracture care".1 If the emergency physician does not provide restorative care and definitive treatment2 of a F/D, the preferred means of reporting this service would be to use Emergency Department Evaluation and Management codes, and to include the appropriate procedure code if a cast or splint was applied. (see FAQ number 5).

Since emergency physicians often provide only the initial management for F/D conditions and not the usual follow-up care, the -54 modifier (Surgical care only) should be appended to the appropriate F/D code to communicate when the emergency physician provides initial care only.


1. CPT Assistant, February 1996. Coding the Evaluation of a Fracture in the Emergency Department.

2. CPT Assistant, December 2001. Coding Consultation: Musculoskeletal System, Surgery, 28450 (Q&A).


FAQ 2:  Can emergency physicians code for fracture care where no manipulation is required? For example, what does the uncomplicated rib fracture code CPT 21800 include?

As in all of the CPT surgical codes, use of an unmodified 21800 ("Closed treatment of rib fracture, uncomplicated, each"), indicates that the physician is providing restorative care and any subsequent patient care usual to the management of this condition. Therefore, the emergency physician's overall management should be comparable to that provided by other physicians performing the same service (e.g., exclude complications, treat pain, provide patient education, stabilization where appropriate, and follow up as needed), and take into account the patient's relevant circumstances. Of course, if the emergency physician does not expect to provide the follow up care usual for such condition, a -54 modifier should be appended to the code.


FAQ 3:  Does moderate (conscious) sedation qualify for the orthopedic codes that indicate "with anesthesia," or does one utilize the moderate conscious sedation code in addition to the procedure?

According to CPT 2012, moderate sedation (formerly known as conscious sedation) is distinguishable from general anesthesia in that moderate sedation "...is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation." While there is no specific reference in CPT, AMA personnel have stated that "with anesthesia" means "with general anesthesia." As a result, the best way to code orthopedic services in conjunction with moderate sedation is to use the orthopedic codes "without anesthesia," and, if appropriately performed and documented, to report the respective moderate conscious sedation codes. Please see ACEP's Moderate Sedation FAQ for details on coding moderate sedation.



FAQ 4:  Can one code/bill separately for X-ray interpretation in addition to orthopedic procedure codes?

CPT states that surgical procedures include the operation per se, local infiltration, metacarpal/digital block, or topical anesthesia when used, and normal, uncomplicated follow-up care. Radiological interpretations are not listed as part of the surgical package, and therefore, can be coded separately when performed and documented appropriately.


FAQ 5:  Under which conditions can an emergency physician apply a splint/strap procedure code (CPT 29000 - 29799)? Does the physician have to personally apply a splint/strap in order to utilize these codes?

The CPT-identified splint/strap services are described in CPT as being provided in order to "stabilize, protect or provide comfort". The CPT codes for these services can be applied by the emergency physician for the replacement or initial application except when the splint/strap is part of any restorative care (when restorative, use appropriate orthopedic service code - see FAQ number 1).  Thus one may either utilize the splint/strap code or the fracture management code for restorative care, but not both.

If a physician personally applies and adequately documents the application of a splint or strap then a splint/strap application procedure code may be utilized. Local payer rules may place limits on coding for direct supervision only. Physicians are advised to confirm the acceptability of coding and billing for direct supervision of splint/strap application with these carriers.


FAQ 6:  If the initial stabilization for a fracture is provided before surgical intervention, can one use the fracture care code with a -56 modifier?

A temporary cast/splint/strap is not considered to be part of the pre-operative care, and use of the -56 modifier ("Preoperative Management Only") is not appropriate. An Evaluation/Management service would be appropriate, together with a cast/splint/strap code, in these cases.


FAQ 7:  Can one charge an Evaluation/Management service in addition to the orthopedic procedure codes?

If the E/M service is for a significant "separately identifiable" medical service not directly related to the reported orthopedic care (e.g., fracture/dislocation care or splint/strap services) then an E/M code modified with -25 may be used to identify a significant, separate E/M service.


FAQ 8:  What is the difference between closed treatment of a nasal bone fracture without manipulation (CPT 21310) and without stabilization (CPT 21315)?

CPT 21310 is restorative care for a presumably stable, non-displaced nasal fracture, where no physical manipulation of the nasal bone or stabilization of the fracture (e.g., splint, skeletal fixation) is necessary.

CPT 21315 presumes manipulation of the fractured bone (e.g., using nasal elevators or forceps) to achieve proper alignment; and, once the bones are realigned, the fracture does not require additional stabilization.

In either instance, if the physician in the emergency department does not intend to provide the indicated subsequent care required for the respective code, then the service ought to be reported with the appropriate modifier.


FAQ 9:  What is the difference between "open" and "closed" treatment of a fracture based on CPT definitions?

Per CPT definition, fracture care should be described by the type of treatment rendered and not by the type of fracture. Open treatment refers to the requirement for a surgical incision to expose the fracture for direct visualization. Closed treatment specifically means that the fracture site is not surgically opened. Thus, an emergency physician usually provides closed treatment only, even when caring for an open fracture.


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