What is a “fracture”

FRACTURED
FAIRY TALES
ABOUT
FRACTURES!
By:
Cynthia Everlith,
BSHA, CPC, CMA
Arizona Hand & Wrist
Specialists
a division of
OSNA, PLLC
Objectives
 What is a “fracture”
 Different types of “fractures”
 Closed
l d “fractures”
f
 Open “fractures”
 “Fracture” care
 Ethics
 Medicare Guides
 Modifiers
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 Closed Treatment
 Closed
l d Treatment with
h
manipulation
 Percutaneous Pin fixation
 Open Fracture
 Casting/splinting
FRACTURE
TYPES
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FRACTURES
fracture /frac·ture/
(frak´cher) 1. the
breaking of a part,
especially a bone.
2. a break or rupture in
a bone.
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avulsion fracture separation of a small fragment of bone cortex at the site of attachment of a ligament or tendon.
axial compression fracture fracture of a vertebra by excessive vertical force so that pieces of it move out in horizontal
directions.
Barton's fracture fracture of the distal end of the radius into the wrist joint.
Bennett's fracture fracture of the base of the first metacarpal bone running into the carpometacarpal joint, complicated by
subluxation.
blow-out fracture fracture of the orbital floor caused by a sudden increase of intraorbital pressure due to traumatic force; the
orbital contents herniate into the maxillary sinus so that the inferior rectus or inferior oblique muscle may become incarcerated in
the fracture site, producing diplopia on looking up.
burst fracture axial compression f.
capillary fracture one that appears on a radiogram as a fine, hairlike line, the segments of bone not being separated; sometimes
seen in fractures of the skull.
closed fracture one that does not produce an open wound in the skin; cf. open f.
Colles' fracture fracture of the lower end of the radius, the lower fragment being displaced backward; if the lower fragment is
displaced forward, it is a reverse Colles' fracture.
comminuted fracture one in which the bone is splintered or crushed.
complete fracture one involving the entire cross section of the bone.
compound fracture open f.
depressed fracture , depressed skull fracture fracture of the skull in which a fragment is depressed.
de Quervain's fracture fracture of the navicular bone together with a volar luxation of the lunate bone.
direct fracture one at the site of injury.
dislocation fracture fracture of a bone near an articulation with concomitant dislocation of that joint.
Dupuytren's fracture Pott's f.
Duverney's fracture fracture of the ilium just below the anterior inferior spine.
fissure fracture a crack extending from a surface into, but not through, a long bone.
freeze fracture see freeze-fracturing.
greenstick fracture one in which one side of a bone is broken, the other being bent.
hangman's fracture fracture through the pedicles of the axis (C2) with or without subluxation of the second cervical vertebra or
the third.
impacted fracture one in which one fragment is firmly driven into the other.
incomplete fracture one which does not entirely destroy the continuity of the bone.
insufficiency fracture a stress fracture that occurs during normal stress on a bone of abnormally decreased density.
intrauterine fracture fracture of a fetal bone incurred in utero.
Jefferson's fracture fracture of the atlas (first cervical vertebra).
lead pipe fracture one in which the bone cortex is slightly compressed and bulged on one side with a slight crack on the other
side of the bone.
Le Fort fracture bilateral horizontal fracture of the maxilla. Le Fort fractures are classified as follows: Le Fort I f., a horizontal
segmented fracture of the alveolar process of the maxilla, in which the teeth are usually contained in the detached portion of the
bone. Le Fort II f., unilateral or bilateral fracture of the maxilla, in which the body of the maxilla is separated from the facial
skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline
of the hard palate, through the floor of the orbit, and into the nasal cavity. Le Fort III f., a fracture in which the entire maxilla and
one or more facial bones are completely separated from the craniofacial skelton; such fractures are almost always accompanied by
multiple fractures of the facial bones.
Monteggia's fracture one in the proximal half of the shaft of the ulna, with dislocation of the head of the radius.
open fracture one in which a wound through the adjacent or overlying soft tissues communicates with the site of the break.
parry fracture Monteggia's f.
pathologic fracture one due to weakening of the bone structure by pathologic processes, such as neoplasia, osteomalacia, or
osteomyelitis.
ping-pong fracture a type of depressed skull fracture usually seen in young children, resembling the indentation that can be
produced with the finger in a ping-pong ball; when elevated it resumes and retains its normal position.
Pott's fracture fracture of the lower part of the fibula, with serious injury of the lower tibial articulation, usually a chipping off of a
portion of the medial malleolus, or rupture of the medial ligament.
pyramidal fracture (of maxilla) Le Fort II f.
sagittal slice fracture fracture of a vertebra breaking it in an oblong direction; the spinal column above is displaced horizontally,
usually causing paraplegia.
silver fork fracture Colles' f.
simple fracture closed f.
Smith's fracture reverse Colles' f.
spiral fracture one in which the bone has been twisted apart.
spontaneous fracture pathologic f.
sprain fracture the separation of a tendon from its insertion, taking with it a piece of bone.
Stieda's fracture fracture of the internal condyle of the femur.
stress fracture that caused by unusual or repeated stress on a bone.
t
f i lf
t
L F t III f
 The restoration of a body part to
closed reduction the
manipulative reduction
of a fracture without
incision.
open
reduction reduction
of a fracture after
incision into the
fracture site.
its original position after
displacement, such as the
reduction of a fractured bone by
b i i ends
bringing
d or ffragments b
back
k
into original alignment. The use
of local or general anesthesia
usually accompanies a fracture
reduction. If performed by
outside manipulation only, the
reduction is described as closed; if
surgery is necessary, it is
described as open.
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Toe Fracture
Intra-articular
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Closed reduction with
Percutaneous pin
fixation
ICD-10
Glimpse……
 A=Initial encounter for closed fracture
 B=Initial encounter for open fracture
t
type
I or II
 C=Initial encounter for open fracture
type III
 D=Subsequent encounter for routine healing
 E=Subsequent encounter for open fracture
type I or II routine healing
 F=Subsequent encounter for open fracture
type III routine healing
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Fracture Global Care
 There are two common approaches at this
time that can be used when coding
nonmanipulative fracture care services.
services The
American Academy of Orthopaedic
Surgeons (AAOS) and the American
Medical Association (AMA) support these
two approaches. The AMA has published
several articles in the CPT Assistant to
reflect how these options work. The two
common approaches/methods are:
 Fracture global fees
 Alternative method for fracture fees
In the AAOS Guide to CPT Coding for Orthopaedic
Surgery, the definition of fracture global fees reporting
method states:
Fracture global fees may include the hospital/office encounter in
some payment areas. In others, CMS allows you to code an E&M
service with a —57 modifier within the global period if the visit
was the one in which the decision to perform the procedure was
made…. The initial cast is applied, and all revisits, excluding
radiographs that are obtained by the physician, should be
included within a 90-day period from the time of the initial
fracture. All recastings are on an ‘encounter’ basis and are billed
separately.
Here’s the AAOS definition of the alternative method:
Only when treatment of the fracture does not consist primarily of
a ‘procedure’ (for example, closed treatment without
manipulation), services may be itemized as if the problem were
recognized as an office encounter.
encounter Examples include an
undisplaced fracture of the fifth metatarsal; a fracture of the
pelvis, undisplaced or minimally displaced; or a compression
fracture of a vertebra. Office, hospital, and emergency department
encounters are coded as appropriate, as are all injections,
supplies, casts, or treatment program necessities….
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Open
p Reduction
Internal Fixation
with plates and
screws
Billing
OV, X-ray, cast application,
li
supplies
vs
Global package, 90 day follow-up
No initial cast application.
Good, bad, indifferent?????
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Business Decision
You need to decide if the RVU value
f it
for
itemized
i d billi
billing outweighs
t i h the
th
global package.
What if a patient comes into your
office with a fractured clavicle. It is
not displaced and has good
position. The patient is given a
sling and told to follow up PRN.
What should be charged? Can the
office bill fracture care? Why and
whyy not?
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Fracture care
SPLITTING FEES
WHEN SHOULD IT BE DONE?
DOES IT HAPPEN?
Physician Reimbursement
Approximately
17% pre-operative
63% operative
20% post-operative
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Fractured
Femur
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Femoral rod fixation
Question
So what should be done?
The patient was injured on the slopes of Aspen and
lives in New Jersey. Has surgery in Aspen, but then
goes home. Who should get the $$$$?
What questions on this situation arise? What is the
right thing?
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Modifiers
If the surgeon knows that the
patient is not staying for post-op
care. They should apply modifier
-54 (surgical care only)
There should be a phone call and or
written documentation from the
performing surgeon to the
orthopedist in a transfer of care
The orthopedist accepting care
should bill same surgery code with
modifier -55 (post-operative)
CMS 1500
If you are the treating physician and you are billing for
pre and intra
intra-operative
operative care you must put the DOS on
the from/to date service line.
If you are billing for transfer of care for fracture
care the physician accepting the transfer must put the
care…the
date seen.
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Left-Intramedullary rod
Right-plate and screw
fixation
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What if the patient is seen by
another physician in your practice
during a global period…
Or…
If it was a closed reduction without
manipulation, which fee alternative
did you use?
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References
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AAOS Complete Global Service Data for Orthopaedic Surgery 2011
CPT changes 2011 AMA
AMA Category III codes
Video clip “Fractured Fairy Tales, retrieved from youtube
Video clip “Skiing Montague”, retrieved from youtube
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