Nonoperative Fracture Care: The 90-Day Global and How to Bill It

Managing a fracture nonoperatively is skilled longitudinal care, the reduction, the follow-up, the serial imaging, the judgment calls about healing. The billing should reflect all of it. Yet nonoperative fracture care is one of the areas of orthopaedic billing where the rules are most commonly misunderstood, and where both undercoding and inadvertent unbundling errors are most common. The key concept is the fracture care package.

What the Fracture Care Package Includes

When you bill a fracture care CPT code (for example, 25600 for a distal radius fracture treated without manipulation, or 25605 for one treated with manipulation), that code covers a global package that includes:

• 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-ray interpretation during the global period (if separately reported by you, it cannot also be bundled here)

This is why billing a separate E/M on the same day as a fracture care code is typically not appropriate, the fracture care code already includes the evaluation component. The evaluation of the fracture and the decision to treat nonoperatively are built into the fracture care package.

The Exception: Separately Identifiable Service on the Day of Fracture Care

If you address a problem that is unrelated to the fracture on the same day, Modifier 25 can be applied to the E/M. For example, a patient presents with a wrist fracture and also has new chest pain you evaluate and address. The chest pain evaluation is unrelated to the fracture and can be billed separately. The documentation must clearly support the distinct service.

Treatment vs. No Treatment: A Key Distinction

There is an important billing distinction between:

• Billing a fracture care code: You are taking over management of the fracture. The global period begins. All subsequent fracture-related visits are bundled.
• Billing an E/M for fracture evaluation without assuming management: You evaluate the fracture but refer the patient elsewhere for definitive management, or you determine no treatment beyond the ER splint is needed. In this case, the fracture care code may not be appropriate, and the visit can be billed as an E/M.

This distinction matters in settings like emergency consultations, urgent care follow-ups, or cases where you evaluate a fracture and direct the patient to a specialist for ongoing care.

Common Fracture Care Codes and Their wRVU Values

Casting and Strapping: Separate vs. Bundled

Initial cast application is included in fracture care codes that involve manipulation. For fractures treated without manipulation (where you apply a splint or cast at the initial visit), there is a nuance: if no fracture care code is being billed, cast and strapping codes (29000–29590 series) can be billed separately. If a fracture care code is billed, the initial cast application is generally considered bundled.

Subsequent cast changes during the global period are bundled into the fracture care package. If a cast change requires significant additional clinical evaluation, Modifier 25 rules apply (see Chapter 6 ).

Can You Code an E/M Visit With Fracture Care? Yes, With the Right Modifier

A common and costly misconception is that fracture care never carries a separate E/M. It can. The American Academy of Orthopaedic Surgeons has made this explicit: you may code a separate E/M visit on the same day as a fracture-care procedure when that visit is the encounter where the decision for definitive treatment was made, and the documentation shows it. The mechanism is the same global-period logic that governs all surgery.

Here is the part that surprises people. Most fracture-care codes, with or without manipulation, carry a 90-day global period, which classifies them as major procedures. That means the correct modifier on the decision visit is usually Modifier 57 (decision for surgery), not Modifier 25. Modifier 25 is for the minor procedures with 0 or 10-day globals. So when you evaluate a new fracture, decide on and render definitive treatment that day, you can code the E/M with Modifier 57 and the fracture-care code together. Without the modifier, the E/M is denied as part of the global package.

Treating to Completion: The Package Versus Per-Visit Choice

You also have a genuine choice in how to code fracture care, and it is a decision you make and document, not an automatic rule. One option is the definitive fracture-care code, which behaves like a surgical package: one code covers the restorative treatment and the routine follow-up across the 90-day global. The other option is to code an E/M at each visit plus the cast or splint application, rather than the global package. Both are legitimate; what matters is that your documentation matches the choice.

The deciding distinction is definitive, restorative management versus interim stabilization. If you have taken responsibility for treating the fracture to completion and are managing it as a package, payers expect the single definitive code, not a series of separately billed visits within the same period. If instead you are providing temporary stabilization and referring on, or the clinical picture genuinely calls for ongoing evaluation rather than packaged care, the E/M-plus-application approach fits. The one thing you cannot do is double-dip: bill the global package and then also itemize separate E/M visits for routine fracture follow-up within that global period. Note also that an unrelated problem during the global period is separately codable with Modifier 24, and that X-rays are separately reportable and not part of the fracture package.

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