Distal radius fractures are among the most common fracture types, accounting for nearly 18% of fractures in the eldery1 and 25% of pediatric fractures.2–5 Total costs associated with pediatric distal radius fracture treatment have been estimated to be more than $2 billion annually,6 and the open treatment of distal radius fractures in the elderly was estimated to be more than $170 million in a Medicare population.7 Thus, in addition to contributing to responsible clinical practice, accurate coding and billing of distal radius fracture care is critical to minimizing costs to the health care system at large. However, although coding and billing practices in the open treatment of fractures and closed treatment of fractures with manipulation are relatively straightforward, coding of closed treatment of distal radius fractures without manipulation can be performed using 2 distinct methods: (1) global fracture care or (2) billed per visit. These 2 different methods could potentially create a disparity in care and pay, and the preferred method is not standardized.
Global fracture care billing was originally introduced by the Centers for Medicare & Medicaid Services in 1992 to clarify coding for patients who concurrently received open treatment of 1 injury and closed treatment of a separate, distinct injury.8 In addition, global fracture care billing for the closed treatment of fractures without manipulation became classified as a major surgery code with an associated 90-day follow-up period. When billed in this manner, providers code for the initial service of evaluation and management, as well as the global fracture care code. All imaging services and all cast or splint applications (exclusive of the first application, which is included within global care) are also separately billed. All subsequent follow-up visits during the 90-day global period are billed using Current Procedural Terminology (CPT) code 99024 as a postoperative visit similar to the postsurgical global postoperative period. In total, the global fracture care code results in primarily up-front payment at the beginning of treatment for the following 90 days.
The second method, an alternative for coding and billing of the closed treatment of fractures without manipulation, bills through an itemized fashion. Using this method, providers do not use a global fracture care code and instead bill each visit separately, starting with the initial evaluation and management service, the initial splint or cast application, and subsequent follow-up visits, imaging costs, and splint or cast applications. This does not result in a global 90-day period in which visits are billed as “postoperative,” and the provider instead bills according to the specific evaluation and management service provided at each visit. In total, the physician is paid for each service separately instead of a single up-front payment from the initiation of global fracture care.
The Centers for Medicare & Medicaid Services guidelines for billing and coding do not specify a preferred method of coding for closed treatment of fractures without manipulation by providers.8 Thus, billing for these patient care episodes may be done in a global or itemized fashion at the discretion of the provider. The American Academy of Orthopaedic Surgeons (AAOS) recently issued guidelines related to coding for closed treatment of fractures that state that providers can use either method.9 For patients receiving manipulation, AAOS guidelines state that providers should only bill using the global method if they provide “restorative treatment” and intend to follow patients until the completion of their treatment for that injury. Restorative treatment of a fracture is defined as using manually applied forces to restore limb alignment and function. This includes closed reduction of a fracture, as well as application of a cast or splint to maintain alignment. For patients who do not require closed reduction, restorative care means achieving satisfactory alignment for healing and limb function even if that does not require manipulation. Similarly, for nonorthopedic providers, global fracture care billing should only be used if these providers are responsible for restorative care and intend to follow patients until the completion of their treatment for that injury.
The 2 methods ideally should not impact patient care, but only affect reimbursement. The optimal technique to maximize reimbursement to the provider primarily depends on the number and frequency of follow-up visits within the 90-day global period. To the current authors' knowledge, there is currently no published literature regarding the preferred coding method for providers and the effect of these coding methods on patient care or reimbursement. To understand these effects, the closed treatment of distal radius fractures without manipulation was selected as a case example for billing practices, due to its high incidence and substantial cost implications for the health care system.
The goal of this study was to characterize the cost and the effect on patient care of billing practices in the treatment of distal radius fractures. The authors hypothesized that patients billed with an itemized fee structure would have a greater number of follow-up visits during the global period than patients billed with a global fee.
Materials and Methods
A retrospective review was performed using the MarketScan Research Database (IBM, Armonk, New York), which provides integrated, de-identified, patient-specific claims data for between 17 and 51 million patients in the United States annually. Due to its de-identified nature, this study was exempt from receiving institutional review board approval. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify patients diagnosed with a distal radius fracture during the study period of 2003 to 2014. Only patients who were continuously enrolled in the database for 6 months after their diagnosis date were selected to avoid selecting patients who ultimately underwent surgery (Figure 1). Patients with a CPT code for surgical treatment were excluded, as were patients who underwent closed treatment with manipulation, selecting only those patients who were treated for a distal radius fracture without manipulation or surgical treatment. Using the CPT code for closed treatment of a distal radius fracture without manipulation (25600), 2 study groups were then defined: (1) those in which global fracture care was initiated and (2) those in which itemized billing was performed. Queries were then performed to identify the specialty of the provider initiating global fracture care, the likelihood of patients to be seen in follow-up after the initial diagnosis, and the number of office visits during the global period (90 days). To isolate only those visits related to fracture care during the 90-day period after injury, only those visits associated with specific ICD-9 diagnosis codes related to wrist or forearm pain or injury were selected.
Flowchart demonstrating the strategy used to place patients into the global fracture care and itemized billing groups. Abbreviations: CPT, Current Procedural Terminology; ICD-9, International Classification of Diseases, Ninth Revision.
Statistical analyses of population proportions were performed using chi-square test for large samples. Comparisons of population means were performed using 2-tailed independent t tests. Significance was set at P<.05.
A total of 381,561 patients were identified based on inclusion criteria during the defined study period. Global fracture care billing for closed treatment of a distal radius fracture without manipulation was initiated for 177,153 (46.4%) patients. Itemized billing was performed for 204,408 (53.6%) patients with distal radius fractures who did not receive surgical treatment or manipulation during the same period. Demographics are listed in Table 1. Overall, the average age of patients treated for a distal radius fracture was 27.2 years, and 51.4% were female. The average age of patients in the global fracture care group was 23.3 years, and 50% were female. The average age of patients in the itemized billing group was 30.6 years, and 52.6% were female. Patients in the global fracture care group were significantly younger and significantly more likely to be male than patients in the itemized billing group (P<.05).
In the global fracture care group, the average time between fracture diagnosis date and initiation of closed treatment date was 1.75 days, and the most common day of global fracture care initiation was on the day of diagnosis (62%). Orthopedic surgeons were the most likely providers to begin global fracture care and did so for 68.9% of patients in this group (Table 2). Emergency physicians were the second most common specialty (6.0%). Other providers (eg, internal medicine, family medicine, physical medicine, and rehabilitation) were responsible for 20.0% of global fracture care initiation, with the remaining 5.1% initiated by providers with no specialty code.
Patient Data by Provider Initiating Global Fracture Care
The number and frequency of follow-up office visits were significantly different between the global fracture care and the itemized billing groups. Patients with global fracture care billing had significantly fewer office visits during the 90-day global period compared with patients with itemized billing who were seen during follow-up (1.3 vs 2.3, P<.05) (Table 1). Additionally, patients for whom global fracture care was initiated were more likely to not receive any follow-up office visits compared with the itemized billing group (39.2% vs 25.4%, P<.05). The distribution of office visits based on billing type is shown in Figure 2. Patients were also separated by the provider initiating fracture care, and patients seen by an orthopedic surgeon were more likely to not be seen during follow-up and to have fewer office visits than patients seen by other providers (Table 2).
Distribution of the number of office visits during a 90-day period after diagnosis by type of billing.
Coding of office visits during the global fracture care period was also evaluated. Among the 107,682 patients in the global fracture care group who were seen in follow-up, 143,190 office visits were coded during the 90-day follow-up period. Of these visits, 3305 (2.3%) were coded correctly as a postoperative visit (CPT code 99024), whereas 139,885 (97.7%) were coded as an alternative office visit with associated charges.
Appropriate coding and billing of fracture care is a fundamental component of practice for orthopedic surgeons, as well as several other specialties. According to the Centers for Medicare & Medicaid Services8 and AAOS,9 2 different options exist for coding closed treatment of fractures without manipulation: (1) global fracture care and (2) per-visit or itemized billing. This study examined distal radius fractures treated without manipulation and found that patients treated with global fracture care were more likely to not receive a follow-up visit in the 90-day global fracture care period and have fewer follow-up visits than patients with itemized billing.
To the authors' knowledge, there is currently no published literature regarding the effect of global or itemized fee structures on patient care despite being a fundamental component of practice. The results of this study suggest that providers who initiate global fracture care, and thus have already billed for 90 days of treatment for a patient, are less likely to provide additional care to that patient during the global period in the form of office visits. Or, conversely, patients for whom global billing is not initiated are more likely to receive additional follow-up office visits, which can be billed during the 90-day period after injury. Although monetary incentives exist to limit care for those patients who have already been billed a global fee and to provide additional office visits for those patients who have not, the actual cause of these results cannot be directly determined.
Previous studies have documented substantial variability in nonoperative fracture treatment protocols,10,11 and the variation of a few visits could be based on the complexity of the fracture or the comfort level of the surgeon with treating distal radius fractures. Potentially, itemized billing is performed for patients with higher complexity injuries whom providers expect will require more frequent follow-up visits. In the current study, patients coded with global fracture care were more likely to be younger and male than patients under an itemized billing structure. It is possible that pediatric or adolescent fractures were more prevalent in this group.
Another unexpected result of this study was that more than 30% of distal radius global fracture care billing was performed by nonorthopedic surgeons. Although many of these providers likely feel comfortable following patients with these injuries, it is unclear how many are trained in understanding findings on serial radiographs that would indicate the need for surgical treatment or reduction. Six percent of providers initiating global fracture care were emergency physicians, who often do not follow patients throughout their 90-day global period. Although it is accepted for emergency physicians to code for closed treatment of a fracture with manipulation plus a modifier denoting that they will not follow the injury after reduction, such is not the case for patients who do not require reduction. Mahoney et al12 reviewed the monetary effect of global fracture care initiation by emergency physicians in the treatment of distal radius fractures, which occurred in every case in their study. They found that in cases without manipulation, an average of $270 of cost was added to the patient's treatment, without any added value to the system.12
When quantifying the number of follow-up visits and likelihood of follow-up by the provider initiating global fracture care, patients seen by orthopedic surgeons are least likely to have follow-up office visits. Because orthopedic surgeons would provide definitive care for these injuries, it is possible that fewer visits were needed to adequately treat the patients. Alternatively, for patients with global fracture care initiated by other providers, a higher follow-up rate could be due to patients needing additional visits with a specialist or second provider for their fracture care.
According to the results of this study, office visits during the global period (which should be billed as postoperative visits) were almost exclusively billed as standard office visits with associated charges. The reason for coding office visits as such is unclear. Potentially, these visits were billed in error or were performed by providers who saw the patient in follow-up but were not the providers initiating global fracture care billing. Further understanding of these billing habits is needed.
The cost implications of additional visits among the itemized group are substantial given the prevalence of distal radius fractures in the population. Based on Medicare reimbursement data, an additional office visit results in approximately $75 of added cost to the patient's care. When just considering the patients included in this study who were enrolled in the itemized group (204,408), more than $15 million of cost was added through an additional office visit. However, it is also important to consider the cost differences between itemized and global fracture care. According to Medicare reimbursement data, global care of a distal radius fracture (CPT 25600) adds $338.77, which equates to more than 3 office visits billed in an itemized fashion after accounting for initial casting charges.
The primary strength of this study was its large sample, providing a broad overview of fracture-related practice patterns in the United States. Some of the weaknesses of this study were intrinsic to examinations of large databases. Namely, the specific clinical details for each patient could not be examined and no explanation of billing practices could be obtained from providers. In addition, this study included both pediatric and adult distal radius fractures in the data set, and it is possible that these 2 populations have different coding, billing, and follow-up practices. There were statistically significant differences in the age and sex of patients between cohorts, although the potential confounding effect of these differences is unknown because there is no standardized follow-up pattern for either pediatric or elderly fractures. On the basis of the demographic data in Table 1, each group was heterogeneous regarding age, with wide standard deviations demonstrated.
Further research is needed to understand the reasoning and clinical impact of these results. However, it is important for policy makers and orthopedic surgeons to understand the reality that itemized and global billing present different incentive structures for providers that will influence their coding and billing practices as well as their clinical practices.
- Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7(6):612–618. doi:10.1097/00001648-199611000-00008 [CrossRef] PMID:8899387
- Landin LA. Fracture patterns in children: analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950–1979. Acta Orthop Scand Suppl. 1983;202:1–109. PMID:6574687
- Cooper C, Dennison EM, Leufkens HG, Bishop N, van Staa TP. Epidemiology of childhood fractures in Britain: a study using the general practice research database. J Bone Miner Res. 2004;19(12):1976–1981. doi:10.1359/jbmr.040902 [CrossRef] PMID:15537440
- Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury. 2007;38(8):913–922. doi:10.1016/j.injury.2007.01.036 [CrossRef] PMID:17628559
- Ward WT, Rihn JA. The impact of trauma in an urban pediatric orthopaedic practice. J Bone Joint Surg Am. 2006;88(12):2759–2764. doi:10.2106/JBJS.F.00046 [CrossRef] PMID:17142428
- Ryan LM, Teach SJ, Searcy K, et al. Epidemiology of pediatric forearm fractures in Washington, DC. J Trauma. 2010;69(4) (suppl):S200–S205. doi:10.1097/TA.0b013e3181f1e837 [CrossRef] PMID:20938308
- Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to Medicare for the treatment of distal radius fracture in the elderly. J Hand Surg Am. 2011;36(8):1282–1287. doi:10.1016/j.jhsa.2011.05.017 [CrossRef] PMID:21705154
- Centers for Medicare & Medicaid Services. Claims Processing Manual, Chapter 12, Section 40, Rev 3747. 2017. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
- Creevy WR, Henley MB, Maley MM. Coding for closed treatment of fractures. AAOS Now. 2017. https://www.aaos.org/AAOSNow/2017/May/Managing/managing04
- Ansari U, Adie S, Harris IA, Naylor JM. Practice variation in common fracture presentations: a survey of orthopaedic surgeons. Injury. 2011;42(4):403–407. doi:10.1016/j.injury.2010.11.011 [CrossRef] PMID:21163480
- Handoll HH, Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(2):CD000314. doi:10.1002/14651858.CD000314 [CrossRef] PMID:12804395
- Mahoney AP, Englehardt KP, Grana WA. Coding practices affect the cost of distal radius fracture care. Am J Orthop (Belle Mead NJ). 2012;41(9):397–400. PMID:23365807
|Characteristic||Global Fracture Care Billing||Itemized Billing|
|Patients, Total no.||177,153||204,408|
|Age, mean±SD, ya||23.3±24.6||30.6±26.1|
|Female, No.a||88,603 (50.0%)||107,575 (52.6%)|
|Patients with no 90-day office visits, No.a||69,471 (39.2%)||51,994 (25.4%)|
|90-day office visits per patient, mean±SD, No.a,b||1.3±0.83||2.3±1.40|
Patient Data by Provider Initiating Global Fracture Care
|Provider||Total No. of Patients||Patients With Office Visit Within 90 Days||Mean±SD No. of Office Visits|
|Orthopedic surgeon||122,035 (68.9%)||57.2%||1.18±0.58|
|Emergency physician||10,670 (6.0%)||73.2%||2.10±1.37|
|Other provider||35,410 (20.0%)||70.4%||1.45±0.96|
|No provider code available||9038 (5.1%)||54.5%||1.38±0.89|