How To Accurately Code Closed Fracture Care?
Accurate coding of closed fractures is crucial for orthopedic practices to reduce denials, ensure proper reimbursement, and streamline the revenue cycle with proper documentation.
Orthopedic Billing And Coding Guidelines
Accurately coding closed fracture care is crucial for orthopedic practices to avoid costly claim denials and ensure proper reimbursement. With fractures being common in orthopedic offices, providers must be well-versed in the nuances of coding for non-surgical closed fractures without manipulation. Recent changes in coding guidelines have made this task more complex, contributing to the high claim denial rates faced by orthopedic physicians, as one of the highest in healthcare at 18%.
Coding errors often lead to these denials, and understanding the correct process for fracture care coding is essential. By following the right protocols, orthopedic practices can reduce denials, streamline their revenue cycle, and ensure accurate claims and prior authorizations are submitted from the start.
Closed Fracture And Coding Guideline
A closed fracture is a type of bone fracture where the bone breaks but does not penetrate or break through the skin. This means that the fracture is contained within the body, and there is no visible wound or open wound where the bone is exposed. Closed fractures can be classified as either displaced (where the bone ends are misaligned) or non-displaced (where the bone remains in proper alignment despite the break).
Coding Guide for Closed Fractures
The coding of closed fractures is primarily done using the International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) for diagnosis and the Current Procedural Terminology (CPT) for procedures. Below is a general guide:
ICD-10-CM Codes
- Closed fractures are classified under the S code range in ICD-10-CM (e.g., S02 for skull fractures, S22 for rib fractures, S42 for fractures of the shoulder and upper arm).
- Each specific fracture type has a separate code based on the location of the fracture (e.g., S82.101A for a closed fracture of the right tibia, initial encounter).
- The laterality (left or right) and specific site of the fracture must be accurately noted.
- The episode of care must also be captured, such as initial encounter, subsequent encounter, or sequela (complications).
CPT Codes for Fracture Care
- Closed fractures often require fracture care procedures like closed reduction, which is coded separately from the diagnosis.
- CPT codes for fracture care depend on the type and complexity of the treatment provided:
- CPT 25600-25607 for upper extremity fractures.
- CPT 27700-27708 for lower extremity fractures.
- CPT codes for closed reduction (e.g., CPT 27506 for closed reduction of a lower leg fracture).
- CPT codes for cast application or immobilization may also be used (e.g., CPT 29075 for application of a cast).
Modifiers
- Modifiers may be necessary to indicate specific circumstances or the complexity of care (e.g., modifier -RT for right side or modifier -LT for left side).
Documentation
- Proper and thorough documentation is critical to ensure that the correct ICD-10-CM and CPT codes are assigned. This includes detailed descriptions of the fracture type, the method of treatment, and the laterality of the injury.
ICD-10 Code S92.909A: Unspecified Closed Fracture of the Foot (Initial Encounter)
Among the provided codes, S92.909A is the appropriate and specific ICD-10-CM code for a closed fracture if it aligns with the diagnosis being documented. Here's why:
S92.909A Details
- Description: "Unspecified fracture of unspecified foot, initial encounter for closed fracture."
- Usage: This code is billable and can be used for reimbursement purposes in cases where the foot fracture is unspecified and documented as a closed fracture.
- Initial Encounter: The "A" at the end of the code indicates that this is being used for the initial encounter to treat the fracture.
Related Groups
The diagnostic-related groups (MS-DRG) listed, such as 562, 563, 963, 964, and 965, are broader categories that group similar injuries or treatments for billing purposes and may apply if:
- The injury includes fractures, sprains, or strains.
- The specific severity is determined (e.g., presence of major complications and comorbidities (MCC) or complications and comorbidities (CC)).
Deciding Between Fracture Care Codes and Individual Visit Billing
When treating fractures, providers must decide whether to use a comprehensive fracture care code or bill separately for each service, such as office visits, supplies, and procedures. Fracture care codes, much like surgical codes, bundle all related services, including follow-up visits and materials, into a single payment and are often reimbursed at a higher rate.
This decision typically depends on the severity and treatment plan for the fracture. Severe cases requiring consistent management and multiple interventions are often better suited for fracture care codes. For minor fractures, such as those that heal with minimal intervention, billing for individual visits and supplies may be more appropriate and cost-effective for both the provider and the patient.
Proper documentation is essential regardless of the chosen approach. Providers must ensure the treatment plan is clearly outlined, with evidence of follow-up care provided to the patient. Additionally, non-surgical fracture care services fall under a 90-day global period, similar to surgical procedures. If billing for the initial evaluation and management service, appending modifier 57 ensures proper reimbursement by distinguishing it from services included in the global package.
Choosing the correct approach depends on the case's specifics, balancing effective treatment with accurate billing practices.
Encounter Types for Fracture Coding
- Initial Encounter (A): For active treatment (e.g., surgery or ongoing care by the same or a different provider).
- Subsequent Encounter (D): For routine follow-up care after active treatment during the healing phase. Note: Use "A" for ongoing active treatment, not automatically switching to "D."
- Sequela (S): For complications or conditions resulting from the injury (e.g., scar formation).
CPT Coding for Fracture Care
- Fracture Treatment Codes: Use codes for “closed treatment without manipulation” when applicable. Append modifier 57 to the initial E/M service to prevent denials, as these services carry a 90-day global period.
- Modifier 54: Use this when the provider offers only surgical care and no follow-up treatment. Note that reimbursement will be reduced accordingly.
- Supplies for Immobilization: Closed treatment requires the application of casts or splints to meet criteria for fracture treatment codes.
X-Ray Coding Best Practices
- Double Billing: If pre- and post-reduction X-rays are interpreted by the same provider, report two units of the radiology CPT code with modifier 76 for the second service.
- Subsequent X-rays: Report these separately, ensuring documentation specifies the number of views and interpretations.
- Laterality: Always include anatomical modifiers (e.g., LT, RT) to avoid claim denials.
Supplies and Miscellaneous Considerations
- Initial Cast Applications: Bill separately only when no fracture care code is reported. If using fracture care codes, the 90-day global period includes initial applications and supplies.
- Temporary Stabilization: Casting or splinting for patient comfort, not part of definitive treatment, is often excluded by payers.
Key Documentation Requirements
To ensure reimbursement, documentation must include:
- Specific fracture details (type, site, laterality).
- Treatment plan and evidence of care provided.
- Orders for radiology services signed by the treating physician.
Accurate Closed Fracture Coding with BillingFreedom Drives Reliable Revenue
“Insanity is doing the same thing over and over and expecting different results.” Orthopedic practices grappling with outdated coding protocols and rising denial rates must embrace change to thrive.
At BillingFreedom, we specialize in accurate closed fracture coding and orthopedic medical billing services, helping practices achieve up to a 70% boost in reliable revenue. Here’s how we make it possible:
- Expert Coding Precision: Our highly trained team ensures compliance with the latest ICD-10 and CPT guidelines, minimizing errors and maximizing reimbursements.
- Proactive Denial Management: We address issues at the source, reducing denial rates dramatically—often dropping them to as low as 1% for our clients.
- Workflow Optimization: We streamline your billing processes through advanced tools and continuous improvement, ensuring long-term financial stability.
Transform your practice with BillingFreedom’s proven solutions. Accurate fracture coding isn’t just about compliance; it’s about creating a foundation for sustained growth and profitability. Contact us today and take the first step toward a smarter, more reliable revenue stream.
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