Fracture Care Billing Issues

Our practice makes every effort to follow the current insurance coding practices for reporting medical services as outlined by HCFA and the American Medical Association. These regulations can be quite complicated, and they often generate lots of questions from our patients. We therefore are providing this page on fracture billing to clear up any confusion caused by complicated rules regarding the billing of fracture care services.

A fracture is often diagnosed on an x-ray and can vary greatly in severity and appropriate treatment options; however, for billing and insurance coding purposes, fracture care is listed in the surgical section of the AMA coding booklets and is subject to special global or surgical package rules regardless of whether these services were provided at the hospital or at the office.

An insurance claim for fracture care will typically document the following:

  • An exam at the documentation level for diagnosis and decision about the best treatment options.
  • An x-ray, which is often used to diagnose the fracture. A postfracture treatment x-ray may also be administered to ensure proper alignment.
  • A fracture code is assigned based on the injury site, type of fracture and whether the treatment is closed or open. Open treatment is usually performed in the operating room in the hospital or outpatient surgery facility, and closed treatment is done in the emergency room or in the office. Because fracture treatment is considered major surgery by the Federal and AMA coding system, however, it will often be reported as surgery on your insurance company’s explanation of benefits.
  • Cast application for the initial work of applying the cast is included in the above fracture code and there is no charge for a global fracture charge. However, if no global fracture code is used, then the initial evaluation, treatment, and cast application will be separately billed and reported. In global fracture care charges, subsequent applications of casts after the initial treatment are separately reportable and billable based on AMA and CPT guidelines.
  • Cast supplies are reported separately.
  • Most routine fractures require several postop visits, which are included at no charge in the fracture global fee if related to the same diagnosis. Separate diagnoses or separate conditions that are addressed on followup visits will be charged on a separate coding system with a separate diagnosis identified in our medical documentation.
  • Postoperative global days vary anywhere from 10-90 days, depending on the insurance company’s definition. Subsequent x-rays, cast application and supplies are separately billable for any fracture global fee schedule. Some of the more serious fractures may need additional surgery and procedures. There are several rules our office is required to use to report those services. Physical therapy, if required, is not included in the surgical global packages and are separate entities and should be referred to those entities for any questions.

I hope this helps you understand a little bit about the charges that are generated from fracture care. Our office staff will be more than happy to discuss any issues with you.

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