Orthopedic Fracture / Dislocation Management FAQ

1. What types of closed management of fractures and/or dislocations are available for emergency physicians?

There are four different forms of closed management of fractures and/or dislocations for emergency physicians:

  • Closed treatment of fracture without manipulation (e.g., 25500 Closed treatment of radial shaft fracture; without manipulation)
  • Closed treatment of fracture with manipulation (e.g., 26755—closed treatment of distal phalangeal fracture, finger or thumb; with manipulation)
  • Closed treatment of dislocation with fracture with manipulation (e.g., 23665—closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation)
  • Closed treatment of dislocation without fracture, with manipulation (e.g., 23650—closed treatment of shoulder dislocation, with manipulation, without anesthesia)

2. When is it appropriate for an emergency physician to utilize closed fracture and/or dislocation management codes? Does ED care and/or follow-up care need to be "restorative" to apply these codes? When should the -54 modifier be used in conjunction with fracture and/or dislocation management codes when describing ED-based care?

Per CPT: “The physician or other qualified health care professional providing fracture/dislocation treatment should report the appropriate fracture/dislocation treatment codes for the service he or she provided. If the person providing the initial treatment will not be providing subsequent treatment, modifier -54 should be appended to the fracture/dislocation treatment codes. Most fracture and/or dislocation management codes are surgical "global care" procedures.  If treatment of a fracture defined above is not performed, report an evaluation and management code,” 2024 CPT Professional Edition, page 127.

The -54 modifier should be appended to the appropriate fracture and/or dislocation management code with or without manipulation to communicate when the emergency physician provides initial care only.

3. Can emergency physicians code for fracture care where no manipulation is required? For example, what does the uncomplicated toe phalangeal fracture code CPT 28510 include?

Per CPT, the definition of closed treatment is: “The treatment site is not surgically opened (i.e., not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation (e.g., application of cast, splint, or strapping), with manipulation, with skeletal traction, and/or with skin traction. Casting, splinting, or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment.” If the emergency physician does not expect to provide the 90-day follow-up care usual for such a condition, a -54 modifier should be appended to the code.

4. Does moderate (conscious) sedation qualify for the orthopedic fracture and/or dislocation codes that indicate "with anesthesia," or does one utilize the moderate conscious sedation code in addition to the orthopedic fracture and/or dislocation procedure code?

According to CPT, moderate sedation (formerly known as conscious sedation) is distinguishable from general anesthesia in that moderate sedation " a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate.” December 2006 page 16 Special Issue 2006 Q&As: Anesthesia Question: Do the phrases "with anesthesia" or "requiring anesthesia" in CPT code descriptors preclude the reporting of anesthesia codes? AMA Comment: It should be noted that there are certain CPT code descriptors in the CPT codebook that include the phrases "with anesthesia" or "requiring anesthesia." These phrases indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care. The appropriate anesthesia code is reported separately. Moderate (conscious) sedation is not an anesthesia service

Please see ACEP's Moderate Sedation FAQ for details on coding moderate sedation.

5. 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.

6. Under which conditions can an emergency physician apply a splint/strap procedure code (CPT 29000–29799)? Does the physician have to apply a splint/strap to utilize these codes personally?

The CPT-identified splint/strap services are described in CPT as being provided to "stabilize, protect or provide comfort." The CPT codes for these services may be reported by the emergency physician for the replacement or initial application, except when the splint/strap is part of any restorative care (when restorative, use the appropriate orthopedic service code - see FAQ number 2). Thus, one may utilize the splint/strap or fracture management codes for restorative care, but not both.

If a physician supervises the application of a splint or strap, then a splint/strap application procedure code may be reported.

7. Can an emergency physician bill for the application of a prefabricated splint?

If an “off-the-shelf” or prefabricated splint is applied, the facility should report the appropriate HCPCS code. The application of a prefabricated splint is included in the E/M and would not be billed as a separate CPT code.

8. What are some common splinting and strapping procedures performed by emergency medicine providers and their corresponding RVUs?

Description of Procedure

CPT Code

Total RVUs

Application of long arm splint (shoulder to hand)



Application of a short arm splint (forearm to hand); static



Application of a short arm splint (forearm to hand); dynamic



Application of finger splint; static



Strapping; thorax



Strapping; shoulder (e.g., Velpeau)



Strapping; elbow or wrist



Strapping; hand or finger



Application of long leg splint (thigh to ankle or toes)



Application of short leg splint (calf to foot)



Strapping; hip



Strapping; knee



Strapping; ankle and/or foot



Strapping; toes




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

10. 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 and/or dislocation management care or splint/strap services), then an E/M code modified with -25 may be used to identify a significant, separate E/M service or -57 to show a separate E/M for the decision for surgery.  For example, if the patient were involved in a fall that resulted in multiple injuries in addition to a fractured wrist, it would be appropriate to bill an E/M code for the overall examination and treatment of the additional injuries and a fracture code as appropriate for the fracture care provided by the emergency physician.

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

  • CPT 21310 was deleted from CPT 2022. According to CPT 2022, “to report closed treatment of nasal bone fracture without manipulation or stabilization, use appropriate E/M code.”
  • 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.


CPT Assistant, September 2019, "Reporting Nasal Bone Vs Septal Fracture Treatment," Page 3.

CPT Assistant, November 2019, "Coding Correction: Reporting Fracture and Restorative Care and Dislocations," Page 12.

CPT Assistant, May 2022, “Reporting Closed Treatment of Nasal Bone Fracture,” Page 5.

12. 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.

13. Can emergency physicians code for rib fractures (CPT 21800)?

The CPT code 21800 for closed treatment of rib fracture, uncomplicated has been retired and can no longer be coded.


14. What are Medicare’s Global Days for the procedures discussed in this FAQ?



Post-Op Days


Closed treatment of nasal bone fracture without manipulation



Closed treatment of clavicular fracture, without manipulation



Treat shoulder dislocation, without manipulation



Treat shoulder dislocation with fracture and manipulation



Treat finger or thumb fx, with manipulation



Treat toe fracture, without manipulation


15. What are some common orthopedic procedures performed by emergency medicine providers and their corresponding RVUs?

Description of Procedure

CPT Code

Total RVUs

Closed treatment of distal radius fracture; without manipulation



Closed treatment of radial head subluxation; with manipulation



Closed treatment of shoulder dislocation; with manipulation



Closed treatment of hip dislocation, traumatic; without anesthesia



Closed treatment of patellar dislocation; without anesthesia



Closed treatment of post hip arthroplasty dislocation; without anesthesia



Closed treatment of proximal humeral fracture; without manipulation



Updated May 2024



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