![]() In this instance, you are not allowed to report the application of the first cast, but you may report subsequent cast applications. Follow-up care within the 90-day global period is included in the global package. If you choose the global fracture care method, report the appropriate code for closed fracture treatment, as well as the evaluation and management (E/M) service with modifier 57 Surgical care only. If you struggle with coding non-manipulative closed treatment of a fracture when casting is used, remember there are two coding methodologies to choose from: Global Fracture Care Method If, however, the provider subsequently applies or replaces the cast during a follow-up encounter, report the procedure code for casting. The application of the cast is inherent to the fracture treatment procedure code. When the provider treats the fracture and then places a cast, report only the CPT® code for the fracture care. When Casting Calls for Separate CodingĪll fracture care codes include the application and removal of the initial cast. Supplies used in closed treatment without manipulation include casts, splints, slings, walking boots, braces, and crutches. These stabilizers are usually left in position for four to six weeks and then removed when the fracture is healed.Ĭlosed treatment without manipulation involves the use of medical supplies to stabilize the fracture site while it heals or to support weight-bearing during the healing period. Percutaneous fixation means the provider inserts stabilizing devices, such as pins or wires, through the skin from one bone fragment to the other, usually using imaging guidance. ORIF means the provider repairs the fracture through a surgical incision, often with the use of plates, screws, or rods. Instead, the provider manipulates the fractured bone non-surgically to restore correct alignment. Open reduction with internal fixation (ORIF)Ĭlosed manipulation means the provider does not surgically open the fracture site.Fracture TreatmentĪssign CPT® codes based on the type of treatment. Conversely, a closed fracture does not produce an open wound at the fracture site, and the fractured bone is not exposed to air. Providers might use phrases like “puncture site” or “open wound down to the fracture site” to reference an open fracture. An open fracture means that a fracture fragment has pierced the skin, exposing the fractured bone to air. A fracture may present as either open or closed. Fracture PresentationĪssign ICD-10-CM codes based on the presentation of the fracture. ![]() If you were to use the diagnosis presentation term “open tibial shaft fracture” for CPT® code selection, however, you would inappropriately select 27758 Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage. In this case, the correct CPT® code for the initial treatment is 27750 Closed treatment of tibial shaft fracture (with or without fibular fracture) without manipulation. The provider opts to treat this fracture via closed treatment without manipulation, with subsequent visits for follow-up care. Use the treatment of the fracture to select a procedure code.įor example, a patient presents with an open tibial shaft fracture of the lower right leg. ![]()
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