Pamela Posted Mon 25th of November, 2019 17:40:12 PM
We are seeing a patient with displaced fracture in the office. MD assesses fracture and advises patient that option to cast and treat conservatively or to have surgical intervention. Patient is casted at visit but subsequently decides to have open fracture treatment. Is the initial fracture care (closed) billable? Is there an appropriate treatment timeframe when billing for closed followed by open treatment is appropriate? In general we have never billed for the closed treatment when patient has open treatment within a few days. Is there a source of guidance on the billing for this scenario?
SuperCoder Answered Tue 26th of November, 2019 09:18:01 AM
Thanks for your question.
As per the NCCI edits guidelines:
1. If a physician treats a fracture, dislocation, or injury with an initial cast, strap, or splint and also assumes the follow-up care, the physician cannot report the casting/splinting/strapping CPT codes since these services are included in the fracture and/or dislocation CPT codes.
2. If a closed reduction procedure fails and is converted to an open reduction procedure at the same patient encounter, only the more extensive open reduction procedure is reportable. Similarly, if a closed fracture treatment procedure fails and is converted to an open fracture treatment procedure at the same patient encounter, only the more extensive open fracture treatment procedure is reportable.
In the above two guidelines the cast would not be billed if the provider either plans for a follow up care or closed reduction fails. But, in your scenario, the patient did make a decision to first get the cast done and later he decided to go for open treatment therefore, the cast can be billed with the medical necessity.
You can further get the NCCI guidelines for musculosketal system for fracture care on below link.
If you are unable to open the link do let us know we will provide you the document.
Hope this helps.