“In the past, it has been postulated that a doctor had the option of using a fracture code or using E/M codes to bill for fracture care. With the upcoming changes to E/M reimbursement, it would seem that billing using E/M codes might make for sense for fracture care. Are there any thoughts on these changes upcoming for 2021?”
I would agree that when it came to billing for the treatment of a fracture, physicians had the choice of either billing for the appropriate fracture care/fracture treatment CPT/procedure code or using E/M codes to bill for the treatment of the fracture/fracture care. At face value, this seems pretty straight forward. However, when you look at this situation more closely, it is really not quite as simple as it may seem.
When a patient comes in with an injury to the foot and it is determined that the patient has a non-displaced fracture of a lesser metatarsal, assuming that this is a Traditional Medicare patient, you would be able to bill for the E/M service, the X-rays and the appropriate fracture care code, in this instance CPT code 28470 which is defined as: Closed treatment of metatarsal fracture; without manipulation each. Let’s assume that you decided it would be best to place the patient in a pneumatic CAM WALKER which would be billed to the DMERC. This is not a bad reimbursement for this specific date of service. Of course in the medical record you would need to state how immobilizing the patient’s affected foot in the CAM WALKER would allow the alignment and the apposition of the fracture segments to be maintained and would allow bone callus formation to form at the fracture site. This shows MEDICAL NECESSITY and supports and justifies the billing of the fracture treatment code. The downside is that there is now a 90 day postoperative global period and the only service that can be billed and reimbursed related to the fracture within the 90 day postoperative global period would be X-rays.
The option would be to not bill for the “fracture care code” and bill an E/M service on the initial encounter for the injury/fracture and for each successive encounter when the patient is seen for the fracture. The bottom line is this: E/M stands for Evaluation and Management. Not only do you need to “EVALUATE” the patient and come up with a working diagnosis that shows medical necessity, but you also need to “MANAGE” the patient. In other words, you need to treat the problem. If you immobilized the affected foot on the initial encounter, aside from taking follow up/post fracture radiographs, what else are you going to do on the follow up visits to treat the fracture? There isn’t anything else. Additionally, are you really going to have to see the patient more frequently then if you billed the fracture care/treatment code? I don’t think so. After all, it still comes down to Medical Necessity. Is there an advantage to not bill the fracture care code and bill E/M services subsequent to the initial encounter for fracture care? Do the math. I don’t think so.
So, as of January 1, 2021, if the patient has Traditional Medicare or a Medicare Advantage Plan, changes are being put into effect for E/M services as long as the patient is seen in an office or outpatient place of service. The E/M service will be based upon either a “medically appropriate history and/or examination” and Medical Decision Making or based upon Time. If the same scenario as stated above takes place, does it make more sense to bill E/M services in lieu of the appropriate fracture care/treatment code? Even though it will be theoretically easier to achieve the appropriate level of E/M service and the E/M services should reimburse at a higher level, are we really doing anything differently than we were using the “old” E/M guidelines? I think not. It still makes more sense to me to bill the fracture care/treatment code.
This is my opinion.
Michael G. Warshaw
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