Who Receives the Reimbursement for Fracture Care?

WPS Medicare frequently receives requests for redetermination where both the Emergency Department (ED) provider and an orthopedic surgeon bill a fracture care code which has a 90 day global period. Who should be billing? The simple answer is the person who really fixes the fracture, bills for the fracture care service.

The "management" of fracture care in the ED is not billed as the fracture code with modifier -52 (reduced service). Similarly, if the ED provider sees a patient who has a fractured hip that needs surgery, the ED provider does not bill the CPT code for a fractured hip non-operative as he/she did not fix/correct the fracture. In the ED, one should bill the appropriate Evaluation and Management (E/M) service (9928X) and the application of a splint, if applied (assuming that the physician personally applies it, and does not just "supervise" its application).

For a few fractures that do not require operations (e.g. impacted humeral heads), there is no procedure code and thus one might argue that a surgical code plus modifier -56 (pre-operative management only) would be appropriate. Modifier -56 is not an appropriate modifier for Medicare billing. Billing for the correction of the fracture will cause a billing problem when the orthopedic surgeon also bills for the correction of the fracture. In this situation, the ED physician's group must make a business decision regarding how they are going to handle the situation where either party (ED physician or orthopedic surgeon) can bill for the service. In evaluating these types of claims, our question would be - who corrected the fracture, the ED physician or the orthopedic physician? Only the physician who corrects the fracture should bill the fracture care.

Page Last Updated: Thursday, 22-Dec-2011 09:05:03 CST