Orthopaedic, Fracture, and Sports Medicine Coding: Global Periods, Injections, and Physicals

Less time in clinic, more wRVUs

When I moved from full clinical time to 80 percent, my productivity went up, because I had learned to code the work I was already doing. In orthopaedics that work hides in the global period, the fracture care package, and the evaluation behind a four-minute injection or a school physical.

Orthopaedic Clinic Coding: E/M and the Global Period

E/M in Orthopaedic Clinic: The Basics

Clinic E/M follows the same 2021 MDM rules as every outpatient specialty, and musculoskeletal complexity maps cleanly onto the MDM table:

• A new patient with an acute fracture, imaging review, and a surgical decision is moderate-to-high complexity.
• An established patient with progressing arthritis where you adjust the plan (injections, surgical timing, PT) is moderate.
• A routine postoperative visit with an unchanged plan may be low, if it is not bundled into the global.

New Patient Consultations in Orthopaedic Practice

New orthopaedic patients often bring multiple problems, imaging review, and a significant risk decision. These visits frequently support a 99204 or 99205, yet many surgeons reflexively code 99203. Document the problems, the imaging you independently interpreted, and the risk of the decision.

Global Surgery Periods: What Gets Bundled

Every surgical CPT code has a global period during which related follow-up is included in the procedure's payment: 90 days for major surgery, most of orthopaedics, and 0 or 10 days for minor procedures. A visit that only checks healing is bundled.

What Can Be Coded During the Global Period

The package includes routine related follow up (99024, no separate payment) and, for Medicare, related complications handled without a return to the operating room. Everything else takes a modifier: 24 on an unrelated E/M, 79 on an unrelated procedure, 78 on an unplanned related return to the operating room, 58 on a planned or staged procedure. The surgical overview guide teaches all six modifiers in one table and the note language each needs.

Two traps. Some commercial payers do pay the related complication visits Medicare bundles, so verify the payer. And the visit where a return to the operating room is decided belongs to the package or the modifier 78 return unless it independently meets an exception in the table.

Procedures and Same-Day E/M: Modifier 25 in Orthopaedics

Modifier 25 applies when a minor procedure and a separately identifiable E/M happen on the same day, meaning you evaluated beyond the indication for the procedure. The injection section shows how to document both halves.

Nonoperative Fracture Care: The 90-Day Package

The rules are unintuitive, and the hardest question is deceptively simple: for this fracture, does the fracture care code or a straightforward E/M pay more? Few can tell at a glance, which is why I built the fracture coding calculator.

What the Fracture Care Package Includes

A fracture care code (25600 for a distal radius fracture without manipulation, 25605 with manipulation) covers a global package:

• The initial care of the fracture on the day of presentation
• All related follow-up visits during the 90-day global period
• Application of the initial cast, splint, or strapping (for the manipulation codes)
• Subsequent cast changes or removal during the global period

X-rays are separately reportable. The evaluation and the decision to treat are built in, so a routine same-day E/M is not appropriate; the two exceptions are covered below.

Treatment vs. No Treatment: A Key Distinction

• Coding a fracture care code: you are taking over management. The global period begins and all subsequent fracture-related visits are bundled.
• Coding an E/M without assuming management: you evaluate the fracture but refer the patient on, or decide nothing beyond the ER splint is needed, the usual emergency consultation and urgent care pattern.

Common Fracture Care Codes and Their wRVU Values

Casting and Strapping: Separate vs. Bundled

If no fracture care code is coded, cast and strapping codes (29000-29590 series) can be coded separately. If one is coded, the initial application and later cast changes are bundled; a cast change that needs significant additional evaluation falls under the modifier 25 rules.

Coding an E/M With Fracture Care: Modifier 57, Not 25

A costly misconception is that fracture care never carries a separate E/M. The American Academy of Orthopaedic Surgeons is explicit: the visit where the decision for definitive treatment is made is separately codable when the documentation shows it. Because most fracture-care codes carry a 90-day global, that decision visit takes modifier 57 beside the fracture-care code, not modifier 25, and without it the E/M is denied as part of the package; the major versus minor rule behind the choice is taught in the surgical overview guide.

The second exception is an unrelated problem on the same day, which takes modifier 25: a wrist fracture patient with new chest pain you evaluate and address.

Treating to Completion: The Package Versus Per-Visit Choice

The choice between the package and per-visit coding is yours to make and document. If you have taken responsibility for treating the fracture to completion, payers expect the single definitive code, which covers restorative treatment and routine follow-up across the 90-day global. If you are stabilizing and referring on, or the picture calls for ongoing evaluation rather than packaged care, an E/M at each visit plus the cast or splint application fits. What you cannot do is both: code the package and then itemize E/M visits for routine follow-up inside the global. An unrelated problem during the period takes modifier 24.

Sports Medicine Procedures: Injections, Aspirations, and Guidance

As a surgeon, my instinct is to operate, and many injection patients are not surgical. But these visits are often the longest of the day: the full conversation about a meniscal tear, nonoperative versus surgery, then the menu of cortisone, hyaluronic acid, PRP, and stem cells. Code only the injection and that discussion earns almost nothing.

Injection and aspiration codes follow joint or bursa size. The two consistently missed opportunities are ultrasound guidance and same-day E/M with modifier 25.

Joint and Bursa Injection Codes by Size

Ultrasound Guidance: A Separate Codable Service

The codes ending in 4, 6, and 11 (20604, 20606, 20611) are the ultrasound-guided versions. They replace, not supplement, the unguided codes. To use them, document real-time guidance, a permanently recorded image (most practices save a still), and your interpretation. Without that, the unguided code is correct.

Tendon, Ligament, and Trigger Point Injections

Modifier 25 With Injection Visits: The Sports Medicine Application

When you examine multiple structures, review the MRI, work through surgery versus nonsurgical management, and then inject, the evaluation is a separate service and often the longer half of the visit. Without modifier 25 it bundles into the procedure and disappears. Document the E/M (problems, data, decision making) and the procedure note separately; the Modifier 25 guide has the language.

Sports Physicals and Pre-Participation Exams

The sports medicine physicians I work with share one frustration: the pre-participation exam turns into a real visit. The form is done, then come the knee that still aches, the headaches since the last concussion, the shoulder that pops, and they get no extra credit. A good pre-participation physical examination (PPE) is real preventive medicine that occasionally finds the murmur or the red flag, and it is undercoded mostly because providers treat it as paperwork.

The Right Code: Preventive Visit vs. Problem-Focused E/M

A PPE for a healthy young athlete is a preventive visit, not a problem-oriented E/M, coded by age and new or established status: 99384 or 99394 for the high school athlete aged 12 to 17, 99385 or 99395 for the collegiate athlete aged 18 to 39. The full preventive code table by age is in the time-based billing guide.

When You Address a Separate Problem at the PPE

If you separately evaluate a clinical problem during the physical, an undiagnosed murmur, a knee complaint that warrants workup, a mental health concern, that evaluation is an E/M with modifier 25 on top of the preventive code. The rules for same-day preventive and problem visits apply: distinct problem, clear documentation, and the patient told an additional charge may apply.

Clearance Letters and Forms: Not Separately Codable

Completing the PPE form, signing a clearance letter, or filling out a school clearance document is part of the preventive visit, not a separate E/M or charge.

Camp Physicals and Other Athletic Clearance Exams

Camp physicals and summer sports clearances are coded like PPEs: a complete age-appropriate preventive exam takes the preventive codes. A limited exam focused only on clearance for one activity is more accurately an E/M at the appropriate level.

A Pre-Participation Exam, Worked Through

A 15-year-old comes in for a school sports physical. If it is purely the pre-participation evaluation, code it as such; the coverage gap above is why these are so often cash visits or miscoded. If the visit turns up exertional chest pain that you work up, you have crossed into problem-oriented E/M and should code it. The frequent error is writing off the whole encounter as a free add-on. That is the pattern of this guide: the procedure, the package, or the form is visible on the schedule, and the evaluation behind it is where the uncoded work lives.

Sources and Further Reading for This Chapter

• AAOS, coding for fracture care. https://www.aaos.org/
• CMS, Global Surgery Booklet (MLN). https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
• CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician