Clearing up the Confusion: Billing and Coding Tips for Fracture Care during a Global Period


Friday Follow: Medical Billing and Coding CPT Drill Down

Clearing Up The Confusion: Billing and Coding Tips for Fracture Care During a Global Period

By Holly Cassano, CPC

This topic has often been met with an over-abundance of moans and groans from the billing and coding community, as it lends itself to what sometimes appear as “gray areas” in the orthopedic arena. If we look at CPT guidelines, services provided that relate to closed treatments are either with or without manipulation and state that they should be billed under a “packaged or global” service.

CPT offers orthopedic surgeons a choice in which to code for closed treatment of a fracture, and they are as follows:

• Report services under the “global” guidelines by using the 90-day, global fracture code. This offers surgeons the option of reporting “with or without” the initial evaluation and management (E&M) service, which indicated the chief complaint and the reason to perform a closed treatment.
• Report services under the “itemized” methodology by reporting every patient encounter separately, hence “itemized.” The surgeon will report services independent of the fracture care which precludes them from having to follow a 90-day global period.

What Can I Charge During a Global Period?
Orthopedics, which also includes spine surgeons, must ensure they are maintaining coding and billing compliance by adhering to any annual updates published in October of every year, for any changes to global surgery packages.

Surgeons who choose the global method to report services also are not required to document in accordance with any specific E&M rules as it is considered a packaged service. Any and all subsequent E&M services that are related to the initial fracture care fall under this package and are within the 90-day global fee, including the application of the first cast or splint. The initial E&M service provided will generally have a 25 or 57 modifier appended, depending on the level of the encounter and specific Payer guidelines.

For example, the initial treatment will include the following:

• The first cast or splint application
• Usually 90 days of normal, uncomplicated follow-up care. (This may vary with different insurance companies/policies). What is not included in the package. (There will be a separate charge)
• Physician evaluation of the fracture
• X-rays
• All casting supplies (fiberglass, Gortex, Ace wraps, slings, cast shoes, etc).
• Any replacement cast application
• The evaluation and management of any additional problems or injuries
• The treatment of complications
• Global and itemized options

How to Report Additional Services during a Global Period:
Additional services supplied and reported within a global period will require modifiers.

• Service other than and E&M service will require the 59 modifier to be appended to the service to indicate the service was separate during the 90-day period.
• E&M services will require modifier 24 to be appended during the 90-day global period to indicate the service was separate during the 90-day period.

• If an orthopedic surgeon were to treat a new issue/problem while a patient is in their 90-day global period, the E&M service would require modifier 24 to be appended to it, as well as a diagnosis code that supported and necessitated the need for a separate Evaluation and Management service in order for the surgeon to be paid.

Itemized Reporting Requirements
Surgeons will be required to provide supporting documentation which indicates medical necessity for the E&M service provided at each subsequent visit.

• E&M first visit: 9920x-25 for a new patient office visit will require modifier 25 to indicate the E&M service provided is significant and separately identifiable as it is associated with another procedure (application of a cast or splint). If the service is provided in any other setting than an office or ER, report modifier 25
• Application of an initial cast or splint
• Supplies for casting/splinting, depending on the place of service
• Subsequent services are reported using established patient visit codes if the services are provided in the office (9921x), or other E&M code that is specific to POS
• Application of replacement cast(s) or splint(s)
•  Supplies, if applicable, depending on the place of service

Final Thoughts
It is mission critical to pay close attention to Medicare and Commercial Payor policies to ensure accurate billing, coding, and reimbursement for these sometimes confusing services. Review guidelines for medical necessity and appeal denials in a timely manner.

For more information on orthopedic guidelines for fracture care, please visit Becker Spine and Karen Zupko.

Happy Coding!