Local Coverage Article Billing and Coding

Billing and Coding: Fracture Care

A52767

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Contractor Information

Article Information

General Information

Article ID
A52767
Article Title
Billing and Coding: Fracture Care
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text
Many times the initial treating physician does not provide all of the follow-up care after surgery. View examples of acceptable ways to bill for definitive or restorative treatment of a fracture.

Coding and Billing Options

Claim Coding Example #1

When the surgeon does not provide any of the follow-up care for the 90 day global payment period, the surgeon bills the closed treatment of radial shaft fracture as follows:
Date Place of Service CPT/Modifier Charge Units
2/15/2014 Applicable Code 25500 54 $$ 1


Second physician bills the follow-up care for the closed treatment of radial shaft fracture as follows:

Date Place of Service CPT/Modifier Charge Units
2/15/2014 Applicable Code 25500 55 $$ 1

Documentation in item 19 of 1500 claim form: 2/16/2014- 5/16/2014

Claim Coding Example #2

When post operative care is provided by both physicians (45 days each), the surgeon bills the closed treatment of radial shaft fracture as follows:

Date Place of Service CPT/Modifier Charge Units
2/15/2014 Applicable Code 25500 54 $$ 1
2/15/2014 Applicable Code 25500 55 $$ 1

Document in item 19 of 1500 claim form 2/16/14-4/1/2014

Second physician bills the closed treatment of radial shaft fracture as follows:
Date Place of Service CPT/Modifier Charge Units
2/15/2014 Applicable Code 25500 55 $$ 1

Document in item 19 of 1500 claim form 4/2/2014-5/16/2014

If the decision to have surgery was made by the surgeon on the day before or the day of surgery, a modifier 57 needs to be appended to the evaluation and management code used. Without this modifier, your visit will be denied as included in the global package of the surgery.

If a patient visit occurs after surgery which is unrelated to the surgical procedure, a modifier 24 must be appended to the evaluation and management code.

To assist physicians and practitioners to select the correct code for the casting, splinting and splinting supplies, the following crosswalk provides guidance on which supply code are applicable for the various types of casts listed by Level I CPT codes.

The splints and cast Q codes are considered Level II codes and to be used when supplies are indicated for cast and splint purposes. The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.

Level I Level II Level I Level II
29000 Q4001 or Q4002 29126 Q4021 through Q4024
29010 Q4001 or Q4002 29130 Q4049
29015 Q4001 or Q4002 29131 Q4051
29020 Q4001 or Q4002 29305 Q4025 through Q4028
29025 Q4001 or Q4002 29325 Q4025 through Q4028
29035 Q4001 or Q4002 29345 Q4029 through Q4032
29040 Q4001 or Q4002 29355 Q4029 through Q4032
29044 Q4001 or Q4002 29365 Q4033 through Q4036
29046 Q4001 or Q4002 29405 Q4037 through Q4040
2949 Q4050 29425 Q4037 through Q4040
29055 Q4003 or Q4004 29435 Q4037 through Q4040
29058 Q4003 29440 Q4050
29065 Q4005 through Q4008 29445 Q4037 through Q4040
29075 Q4009 through Q4012 29450 Q4035, Q4036, Q4039
29085 Q4013 through Q4016 Q4040
29105 Q4017 through Q4020 29505 Q4041 through Q4044
29125 Q4021 through Q4024 29515 Q4045 through Q4048


The allowance for application of a cast, splint or strapping includes removal or repair by the same physician or other physician in the same group. Billing for cast removal or repair (29700-29750) should be employed only for casts applied by another physician group.

Coding Information

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

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Group 1 Codes
CodeDescription
24 UNRELATED EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN DURING A POSTOPERATIVE PERIOD: THE PHYSICIAN MAY NEED TO INDICATE THAT AN EVALUATION AND MANAGEMENT SERVICE WAS PERFORMED DURING A POSTOPERATIVE PERIOD FOR A REASON(S) UNRELATED TO THE ORIGINAL PROCEDURE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -24 TO THE APPROPRIATE LEVEL OF E/M SERVICE, OR THE SEPARATE FIVE DIGIT MODIFIER 09924 MAY BE USED.
54 SURGICAL CARE ONLY: WHEN ONE PHYSICIAN PERFORMS A SURGICAL PROCEDURE AND ANOTHER PROVIDES PREOPERATIVE AND/OR POSTOPERATIVE MANAGEMENT, SURGICAL SERVICES MAY BE IDENTIFIED BY ADDING THE MODIFIER -54 TO THE USUAL PROCEDURE NUMBER OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09954.
55 POSTOPERATIVE MANAGEMENT ONLY: WHEN ONE PHYSICIAN PERFORMS THE POSTOPERATIVE MANAGEMENT AND ANOTHER PHYSICIAN HAS PERFORMED THE SURGICAL PROCEDURE, THE POSTOPERATIVE COMPONENT MAY BE IDENTIFIED BY ADDING THE MODIFIER -55 TO THE USUAL PROCEDURE NUMBER OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09955.
57 DECISION FOR SURGERY: AN EVALUATION AND MANAGEMENT SERVICE THAT RESULTED IN THE INITIAL DECISION TO PERFORM THE SURGERY, MAY BE IDENTIFIED BY ADDING THE MODIFIER -57 TO THE APPROPRIATE LEVEL OF E/M SERVICE, OR THE SEPARATE FIVE DIGIT MODIFIER 09957 MAY BE USED.

ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2021 R4

Under CPT/HCPCS Modifiers, the description was changed for the following modifier:

• 57

This revision is due to the Q1 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 01/01/2021.

10/01/2015 R3

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

10/01/2015 R2

This final article, effective 10/1/15, combines JFA A53330 in the JFB A52767 article so that both JFA and JFB contract numbers will have the same final Medicare Coverage Database (MCD) article number A52767.

10/01/2015 R1 Article was revised for clarification

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
02/11/2021 01/01/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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