June 2002 Bulletin

Understanding fracture care coding

Two common approaches can be used

By Margie Scalley Vaught, CPC, CCS-P, MCS-P

Fracture care coding has changed considerably in the past six years. The CPT code selection is no longer dependent on the type of fracture (open or closed) but on the type of treatment rendered (open, closed, percutaneous, skeletal fixation, manipulation, external fixation, etc.). Adding to this confusion is the dilemma of how to bill and receive reimbursement for nonmanipulative fracture care services.

There are two common approaches at this time that can be used when coding nonmanipulative fracture care services. The American Academy of Orthopaedic Surgeons (AAOS) and the American Medical Association (AMA) support these two approaches. The AMA has published several articles in the CPT Assistant to reflect how these options work. The two common approaches/methods are:

In the AAOS Guide to CPT Coding for Orthopaedic Surgery 2000, the definition of fracture global fees reporting method states:

Fracture global fees may include the hospital/office encounter in some payment areas. In others, HCFA [CMS] allows you to code an E&M service with a —57 modifier within the global period if the visit was the one in which the decision to perform the procedure was made…. The initial cast is applied, and all revisits, excluding radiographs that are obtained by the physician, should be included within a 90-day period from the time of the initial fracture. All recastings are on an ‘encounter’ basis and are billed separately.

Here’s the AAOS definition of the alternative method:

Only when treatment of the fracture does not consist primarily of a ‘procedure’ (for example, closed treatment without manipulation), services may be itemized as if the problem were recognized as an office encounter. Examples include an undisplaced fracture of the fifth metatarsal; a fracture of the pelvis, undisplaced or minimally displaced; or a compression fracture of a vertebra. Office, hospital, and emergency department encounters are coded as appropriate, as are all injections, supplies, casts, or treatment program necessities….

AAOS states that this alternative method of reporting is similar in nature to the reporting of soft-tissue injuries such as sprains/strains.

The relative value units (RVUs) assigned to the fracture global fee method versus the alternative (itemized) method are relatively the same. An example would be treatment of a nondisplaced torus fracture without manipulation in an office setting.

Global Coding


Itemized Coding






(inc initial cast)


(initial + 2)



(2 cast)



(3 visits)


Total RVUs



When deciding whether to code and bill a non-manipulative fracture service, one of the key issues should be provider intent. That intent may consist of the provider performing what he/she believes is more of an evaluation and management of a fracture and not so much a global fracture care service. Another issue in deciding whether to bill the fracture care global CPT code versus itemizing the services can be carrier-driven. Some carriers may require that an office bill for the fracture care code, if there is an appropriate CPT code.

In addition to carriers that require this type of billing, some insurance plans such as accident plans may also require this billing in order to have reimbursement provided for the patient. Each situation will be unique and different. Thus, the provider should be aware of the two options as outlined by the AAOS when it comes to non-manipulative fracture care coding. Practices will want to set up an internal policy that would allow providers to code each situation uniquely.

Below is a grid that can be used to help practices and/or providers understand what should be documented and required for the different methods:

Fracture Care Global Package

Need to apply:

Splint, cast, walking cast/boot, strapping, etc.

90-day treatment plan consisting of:


Itemized Method

No restorative treatment or procedure is performed

ALL services billed separately:

Another issue of fracture care coding that often gets overlooked involves billing and reporting the use of casting supplies. Offices need to remember that when providing cast/strapping (in the office) supplies utilized need to be billed out to the appropriate carrier. Some casting supplies for (continued on p. 32) fracture and/or dislocation care were once included in the RVUs assigned for fracture treatment codes; however, they have been removed from the RVUs assigned for those global fracture care codes. Some of these changes became effective Jan 1, 2001.

Prior to Jan 1, 2001, offices could only code and bill for the plaster and/or fiberglass supplies using HCPCS codes A4580 and/or A4590. The Federal Register (dated July 17, 2000, and Nov 1, 2000) clearly direct providers to bill for ALL casting supplies (padding, stockinet, etc.) and further direct Medicare carriers to reimburse separately for those casting supplies when related to fracture and/or dislocation treatment. These Federal Registers also indicated that offices have all along been allowed to bill and code separately for specialty supplies such as Procel (waterproof cast padding). Many private carriers have not updated their systems to recognize and allow the additional reporting of ALL casting supplies.

Currently Medicare has added over 50 Q codes that offices are to use in reporting these casting supplies. Providers need to document whether plaster or fiberglass is used; whether the patient is over or under 11 years of age and whether the application was for a cast or splint, in order to assign the appropriate Q code. Q code Q4050 is for miscellaneous casting/strapping material, and it is this code that Medicare has indicated offices should use for the reporting of Procel, waterproof cast padding with supporting medical necessity in the patients chart.

Medicare also advises to get a signed and dated Advance Beneficiary Notice (ABN) from the patient if you are using this specialty item, because reimbursement will depend on local carrier policy and medical necessity.

Fracture care coding in an orthopaedic office is usually a high volume service. Offices and providers need to review their current policies on billing and coding to make sure that they stay up-to-date with the changes. Offices need to be proactive in providing their carriers with the above-mentioned updated regulations to correct reporting of fracture care services and supplies.

It is a perfect time to update policy and procedure manuals, as well as compliance manuals, to reflect these changes and to contact carriers to make sure they also are abiding by Federal Rules, under HIPAA where applicable.


AAOS Guide to CPT Coding for Orthopaedic Surgery
Federal Registers July 17 and Nov.1, 2000
CPT Assistant, Feb. 1996
CMS Program Memos
AAOS Complete Global Service Data for Orthopaedic Surgery
Medicare Carriers Manual, sections 2050.1, 2100, 2100.1, 4821, 15010, 15030

Margie Scalley Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

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