Orthopedic Fracture / Dislocation Management FAQ

There are four different forms of closed management of fractures and/or dislocations for emergency physicians:

• Closed treatment of fracture without manipulation (e.g., 23500—closed treatment of clavicular fracture, without manipulation)
• Closed treatment of fracture with manipulation (e.g., 26755—closed treatment of distal phalangeal fracture, finger or thumb; with manipulation)
• Closed treatment of dislocation with fracture with manipulation (e.g., 23665—closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation)
• Closed treatment of dislocation without fracture, with manipulation (e.g., 23650—closed treatment of shoulder dislocation, with manipulation, without anesthesia)

Per CPT: “The physician or other qualified health care professional providing fracture/dislocation treatment should report the appropriate fracture/dislocation treatment codes for the service he or she provided. If the person providing the initial treatment will not be providing subsequent treatment, modifier -54 should be appended to the fracture/dislocation treatment codes. Most fracture and/or dislocation management codes are surgical "global care" procedures.  If treatment of a fracture defined above is not performed, report an evaluation and management code.” 2023 CPT Professional Edition, page 123.

The -54 modifier should be appended to the appropriate fracture and/or dislocation management code with or without manipulation to communicate when the emergency physician provides initial care only.

Per CPT, the definition of closed treatment is: “The treatment site is not surgically opened (i.e., not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation (e.g., application of cast, splint, or strapping), with manipulation, with skeletal traction, and/or with skin traction. Casting, splinting, or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment.” 2023 CPT Professional Edition, page 851.

If the emergency physician does not expect to provide the 90-day follow-up care usual for such a condition, a -54 modifier should be appended to the code

According to CPT, moderate sedation (formerly known as conscious sedation) is distinguishable from general anesthesia in that moderate sedation "...is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate." December 2006 page 16 Special Issue 2006 Q&As: Anesthesia Question: Do the phrases "with anesthesia" or "requiring anesthesia" in CPT code descriptors preclude the reporting of anesthesia codes? AMA Comment: It should be noted that there are certain CPT code descriptors in the CPT codebook that include the phrases "with anesthesia" or "requiring anesthesia." These phrases indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care. The appropriate anesthesia code is reported separately. Moderate (conscious) sedation is not an anesthesia service.  Please see ACEP's Moderate Sedation FAQ for details on coding moderate sedation.

CPT states that surgical procedures include the operation per se, local infiltration, metacarpal/digital block, or topical anesthesia when used, and normal, uncomplicated follow-up care. Radiological interpretations are not listed as part of the surgical package and, therefore, can be coded separately when performed and documented appropriately.

The CPT-identified splint/strap services are described in CPT as being provided to "stabilize, protect or provide comfort." The CPT codes for these services may be applied by the emergency physician for the replacement or initial application, except when the splint/strap is part of any restorative care (when restorative, use the appropriate orthopedic service code - see FAQ number 2). Thus, one may utilize the splint/strap or fracture management codes for restorative care, but not both.

If a physician personally applies and adequately documents the application of a splint or strap, then a splint/strap application procedure code may be utilized. Local payer rules may place limits on coding for direct supervision only. Physicians are advised to confirm the acceptability of coding and billing for direct supervision of splint/strap application with these carriers.

A temporary cast/splint/strap is not considered part of the pre-operative care, and the use of the -56 modifier ("Preoperative Management Only") is not appropriate. In these cases, an Evaluation/Management service would be appropriate, together with a cast/splint/strap code.

If the E/M service is for a significant "separately identifiable" medical service not directly related to the reported orthopedic care (e.g., fracture and/or dislocation management care or splint/strap services), then an E/M code modified with -25 may be used to identify a significant, separate E/M service or -57 to show a separate E/M for the decision for surgery.  For example, if the patient were involved in a fall that resulted in multiple injuries in addition to a fractured wrist, it would be appropriate to bill an E/M code for the overall examination and treatment of the additional injuries and a fracture code as appropriate for the fracture care provided by the emergency physician.

• CPT 21310 was deleted from CPT 2022. According to CPT 2022, “to report closed treatment of nasal bone fracture without manipulation or stabilization, use appropriate E/M code.”
• CPT 21315 presumes manipulation of the fractured bone (e.g., using nasal elevators or forceps) to achieve proper alignment; and, once the bones are realigned, the fracture does not require additional stabilization.

Resources:

CPT Assistant, September 2019, "Reporting Nasal Bone Vs Septal Fracture Treatment," Page 3.

CPT Assistant, November 2019, "Coding Correction: Reporting Fracture and Restorative Care and Dislocations," Page 12.

CPT Assistant, May 2022, “Reporting Closed Treatment of Nasal Bone Fracture,” Page 5.

Per CPT definition, fracture care should be described by the type of treatment rendered and not by the type of fracture. Open treatment refers to the requirement for a surgical incision to expose the fracture for direct visualization. Closed treatment specifically means that the fracture site is not surgically opened. Thus, an emergency physician usually provides closed treatment only, even when caring for an open fracture.

The CPT code 21800 for closed treatment of rib fracture, uncomplicated has been retired and can no longer be coded.