Answers to Your Auditing & Compliance Questions

March 4th, 2019 - Namas
Categories:   Compliance   Emergency Medicine   Pediatrics   Physical Medicine|Physical Therapy  

National Alliance of Medical Auditing Specialists (NAMAS) hosts a forum where auditing and compliance professionals can get answers to their questions, and exchange information with other professionals across the country. Recently, we've received the following question regarding fracture care that we'd like to share below.


Q: I recently noticed CPT 26600, for closed treatment of metacarpal fracture without manipulation. I don't understand why you'd bill for this. If I see a metacarpal fracture in the clinic and bill 99204, then I splint the patient and bill 29125, it seems like double counting to then bill 26600 because if its 'without manipulation', then you are just treating the patient with a splint, which I've already billed for. However, 26600 bills 2.6 wRVUs, so I don't want to miss out an all of the metacarpal fractures that I treat if it applies.

I am not sure I am reading it correctly. Should the provider bill the office visit with a 25 modifier, the treatment of 26600 if he didn't manipulate and the 29125 for applying the splint?


A: There are several things to consider in this scenario. First, the initial splint application is included in the charge for the fracture, so not separately reportable. If he chooses to report the fracture care, the splinting can’t be reported. Also, unless the patient has significant comorbidities that are documented as affecting the complexity of the decision about how to treat the fracture, a level four office visit would not be supported by the medical necessity for a metacarpal fracture. Finally, it is often difficult to support a significant, separately identifiable E&M service above and beyond the typical preoperative and postoperative work included in the reimbursement for the procedure, so it is very possible modifier -57 would not be supported. It all goes back to the documentation. (Modifier -25 is only for minor procedures with 0 or 10-day global periods. -57 is needed when reporting an E&M for 90-day global services.)

There are two schools of thought for billing closed treatment without manipulation of hand/foot fractures. The first is to bill the fracture care and any imaging and supplies used for treatment during the initial visit. This locks the provider into 90 global care, so the follow-up visits are not reportable. If the provider does not expect the patient to actually require follow-up visits then fracture care is really not supported. Reporting this way, the wRVU is 2.60.

The second is to bill in an itemized manner. The E&M and splint application are reported on the first visit, then any follow-up visits are reported separately. For the typical new patient, we would expect 99203 (1.42) and 29125 (0.50) for the initial encounter and 99213 (0.97 x the number of follow-ups necessary) for medically necessary follow-up visits. If only one follow-up visit was necessary, the total wRVUs would be 2.89. As you can see, this is usually the option that is most advantageous to the provider. (All levels of service in this example assume the documentation supports the key elements and medical necessity to report the level of service.)

Also, since most insurance policies apply the fracture care to the patient’s deductible, billing the fracture care potentially creates an upset patient when they receive a perceived large bill for “just putting a splint on it.” Many practices have made a policy to not bill for closed treatment without manipulation in the interest of customer service and patient satisfaction.

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