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Orthopedic Fracture / Dislocation Management FAQ

  • What types of closed management of fractures and/or dislocations are available for emergency physicians?
    Recommendations
    Answer

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

    • Closed treatment of fracture without manipulation (e.g. 23500—closed treatment of clavicular 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)
    Answer

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

    • Closed treatment of fracture without manipulation (e.g. 23500—closed treatment of clavicular 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)
  • 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" in order 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?
    Recommendations
    Answer

    Most fracture and/or dislocation management 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 fracture and/or dislocation, 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 were applied. (see FAQ number 6).

    Since emergency physicians often provide only the initial fracture and/or dislocation management and not the usual follow-up care, the -54 modifier (Surgical care only) 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.

    References:

    CPT Assistant, January 2018, Reporting Fracture and Restorative Care and Dislocations

    1. CPT Assistant, November 2019, Coding Correction: Reporting Fracture and Restorative Care and Dislocations
    2. CPT Assistant, February 1996. Coding the Evaluation of a Fracture in the Emergency Department.
    3. CPT Assistant, December 2001. Coding Consultation: Musculoskeletal System, Surgery, 28450 (Q&A)
    Answer

    Most fracture and/or dislocation management 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 fracture and/or dislocation, 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 were applied. (see FAQ number 6).

    Since emergency physicians often provide only the initial fracture and/or dislocation management and not the usual follow-up care, the -54 modifier (Surgical care only) 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.

    References:

    CPT Assistant, January 2018, Reporting Fracture and Restorative Care and Dislocations

    1. CPT Assistant, November 2019, Coding Correction: Reporting Fracture and Restorative Care and Dislocations
    2. CPT Assistant, February 1996. Coding the Evaluation of a Fracture in the Emergency Department.
    3. CPT Assistant, December 2001. Coding Consultation: Musculoskeletal System, Surgery, 28450 (Q&A)
  • 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?
    Recommendations
    Answer

    As in all the CPT surgical codes, use of an unmodified 28510 ("Closed treatment of fracture, phalanx or phalanges, other than great toe, without manipulation"), indicates that the physician is providing restorative care and any subsequent patient care usual to the management of this condition. Medicare assigns a 90-day follow up to this service.  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 90-day follow up care usual for such condition, a -54 modifier should be appended to the code.

    Answer

    As in all the CPT surgical codes, use of an unmodified 28510 ("Closed treatment of fracture, phalanx or phalanges, other than great toe, without manipulation"), indicates that the physician is providing restorative care and any subsequent patient care usual to the management of this condition. Medicare assigns a 90-day follow up to this service.  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 90-day follow up care usual for such condition, a -54 modifier should be appended to the code.

  • 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?
    Recommendations
    Answer

    According to CPT 2021, 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”. Per CPT Assistant January 1999, "From a CPT coding perspective, codes having the descriptor "requiring anesthesia" mean requiring general anesthesia." Therefore, orthopedic services performed with moderate sedation should be reported with codes describes as "without anesthesia".  If appropriately performed and documented, report the respective moderate conscious sedation codes separately. Please see ACEP's Moderate Sedation FAQ for details on coding moderate sedation.

    However, if deep sedation (anesthesia) is required, the appropriate orthopedic code “with anesthesia” may be used.  References to “with anesthesia” are not intended to replace the reporting of the administration of anesthesia by a separate physician or qualified health care professional, but are intended as a proxy to indicate the complexity of the service.

    Reference:  AMA CPT Assistant; January 2018

    Answer

    According to CPT 2021, 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”. Per CPT Assistant January 1999, "From a CPT coding perspective, codes having the descriptor "requiring anesthesia" mean requiring general anesthesia." Therefore, orthopedic services performed with moderate sedation should be reported with codes describes as "without anesthesia".  If appropriately performed and documented, report the respective moderate conscious sedation codes separately. Please see ACEP's Moderate Sedation FAQ for details on coding moderate sedation.

    However, if deep sedation (anesthesia) is required, the appropriate orthopedic code “with anesthesia” may be used.  References to “with anesthesia” are not intended to replace the reporting of the administration of anesthesia by a separate physician or qualified health care professional, but are intended as a proxy to indicate the complexity of the service.

    Reference:  AMA CPT Assistant; January 2018

  • Can one code/bill separately for X-ray interpretation in addition to orthopedic procedure codes?
    Recommendations
    Answer

    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.

    Answer

    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.

  • 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?
    Recommendations
    Answer

    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 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 2). 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.

    Answer

    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 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 2). 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.

  • If the initial stabilization for a fracture is provided before surgical intervention, can one use the fracture care code with a -56 modifier?
    Recommendations
    Answer

    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.

    Answer

    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.

  • Can one charge an Evaluation/Management service in addition to the orthopedic procedure codes?
    Recommendations
    Answer

    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.

    Answer

    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.

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

    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 a coding correction published by CPT Assistant in January of 2018 following review by the CPT Assistant’s editorial board, reference to use of the -54 modifier for 21310 was determined to be inappropriate and was removed from the article.

    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.

    Answer

    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 a coding correction published by CPT Assistant in January of 2018 following review by the CPT Assistant’s editorial board, reference to use of the -54 modifier for 21310 was determined to be inappropriate and was removed from the article.

    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.

  • What is the difference between "open" and "closed" treatment of a fracture based on CPT definitions?
    Recommendations
    Answer

    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.

    Answer

    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.

  • Can emergency physician’s code for rib fractures (CPT 21800)?
    Recommendations
    Answer

    Since publication of  CPT 2015, the uncomplicated rib fracture code 21800 has been retired and can no longer be coded.

    Answer

    Since publication of  CPT 2015, the uncomplicated rib fracture code 21800 has been retired and can no longer be coded.

Updated April 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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