There is ongoing confusion regarding billing for closed fracture care. The Centers for Medicare and Medicaid Services (CMS) does not have a preference for coding closed nonmanipulative fracture services.1 However, the American Academy of Orthopedic Surgeons’ position is that the providers should be able to choose the method of coding for these services to meet their specific obligations to payers.2  

Per custom procedural terminology, there are two options for coding a closed treatment of a fracture:

  1. The provider can choose to report his/her services under the ‘itemized’ methodology by reporting every patient encounter separately. The surgeon will report services independent of the fracture care which precludes them from having to follow a 90-day global period.
  2. The provider can choose to report his/her services under the ‘global’ guidelines by using the 90-day global fracture care.3

What is required to bill for ‘itemized’ reporting?

  • If the orthopedist performed an evaluation and management (E/M) service as well as appliesa cast/splint, modifier 25 is required to be reported to show that the E/M service is significant and separately identifiable from the cast or splint application.
  • Application of an initial cast/splint is billable as well as supplies for casting/splinting, depending on the place of service and/or whether the provider owns the supplies.
  • Subsequent E/M services are billable (if medical necessity is supported).
  • Application of replacement casts/splint if performed by the provider or supervised staff applies the cast or splint)4

Charges during a Global Period:  

Providers who choose the global method to report their fracture care services are not required to document their E/M visits with History, Exam, & Medical Decision Making as they normally would when billing for E/M services because all of their follow up visits are considered part of the packaged service.5 Any and all subsequent E/M services that are related to the initial fracture care fall under this package and are within the 90-day global package, including the application of the first cast or splint.6 If an E/M service is documented and supports medical necessity, it will require having a modifier 25 appended.7

For example, the initial treatment will include the following:

  • The first cast or splint application
  • Usually 90 days of normal, uncomplicated follow-up visits and care. (This may vary with different insurance companies/policies).8

What is not included in the package? (There will be a separate charge)

  • Physician initial evaluation of the fracture
  •  X-rays
  • All casting supplies (fiberglass, Gortex, Ace wraps, slings, cast shoes, etc).
  • Any replacement cast application
  • The evaluation and management of any additional problems or injuries
  • Global and itemized options9

1CMS Claims Processing Manual Chapter 12 Section 40.4, available at
2American Association of Orthopedic Surgeons News July 2008, available at


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