CurrentHighmark DelawarePolicy RP-005

Coding for Closed Treatment of Fractures and Maternity-Related Anesthesia Add-On Billing

Defines coding rules for closed fracture treatment (restorative vs non-restorative care, global period follow-up, and use of modifiers -54/-55) and billing rules for obstetrical anesthesia add-on codes for Highmark Delaware members.

Policy Summary

PayerHighmark Delaware

PolicyCoding for Closed Treatment of Fractures and Maternity-Related Anesthesia Add-On Billing

Policy CodePolicy RP-005

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionWhen restorative fracture care is provided without follow-up, report the global fracture treatment code with modifier -54; the follow-up provider reports the same CPT with modifier -55.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-dayglobal period referenced for fracture follow-up

2key factors to determine fracture coding

01967,01968obstetrical anesthesia add-on codes discussed

54/55modifiers referenced

Coding and Billing Coverage Criteria

Policy Summary

PayerHighmark Delaware

PolicyCoding for Closed Treatment of Fractures and Maternity-Related Anesthesia Add-On Billing

Policy CodePolicy RP-005

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionWhen restorative fracture care is provided without follow-up, report the global fracture treatment code with modifier -54; the follow-up provider reports the same CPT with modifier -55.

SourceLink

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Coding and billing criteria

Coding rules and accepted reporting methods:

If physician provides restorative treatment and all follow-up within the 90-day global period, report the appropriate global fracture care code.

If physician provides restorative treatment but not follow-up, report the appropriate global fracture treatment code with modifier -54 to indicate only the intra-service (operative/restorative) work was provided.

The provider who performs the follow-up visits during the remainder of the global period should report the same CPT code with modifier -55 to indicate postoperative management only.

If fracture does not require restorative care or post-service follow-up by the same physician, report an appropriate E/M code and the code for application of a cast or splint if applied.

ALL of the following

ONE of
- When the ED physician provides restorative treatment (per restorative definition), report the appropriate global fracture treatment code with modifier -54 to indicate only intra-service work was provided.
- When the ED physician does not provide restorative treatment, report an ED E/M code and the code for application of a cast or splint, if applied.

Obstetrical anesthesia add-on codes (01967, 01968) must be billed on the date of delivery together with the primary service; add-on codes must never be billed as standalone codes or on separate dates and add-on codes submitted without the primary code or with a different date will be rejected and not paid.

Provider Billing Actions and Operational Rules

Billing Rule

Modifier use for split fracture care

Modifier -54: Use when the physician provides only the intra-operative/restorative portion of fracture treatment and will not provide post-operative follow-up care. Report the appropriate global fracture treatment CPT code with modifier -54 to indicate split fracture care. When another physician subsequently performs the post-service follow-up during the remainder of the global period, that physician should report the same CPT fracture code with modifier -55 for the subsequent evaluation and management of the fracture.

Report global fracture code when providing restorative care and follow-up.
If only intra-service (restorative) work is provided, append modifier -54 to the global fracture treatment code.
Subsequent physician providing follow-up care during the global period should report the same CPT with modifier -55.

Billing Rule

ED fracture treatment reporting

ED fracture treatment: Emergency physicians or other qualified ED providers should report services based on the care they actually provide. If the ED physician performs restorative fracture treatment (intra-service work) and will not provide follow-up, report the appropriate global fracture treatment CPT with modifier -54. If the ED physician does not perform restorative fracture treatment, report the appropriate ED E/M code(s) and, if applicable, the code for application of a cast or splint. Do not report global fracture treatment codes without the appropriate modifier when only ED E/M and casting/splinting were provided.

If restorative treatment is provided in the ED and follow-up will be by another clinician, report the global fracture treatment CPT with modifier -54.
If restorative treatment is not provided by the ED physician, report an ED E/M code and casting/splint application code (if applied).
Ensure modifier use is consistent with reporting guidance to avoid incorrect global-period billing.

Key Definitions

inv-07: restorative treatment — definition of manual manipulation/restorative treatment

DefinitionManual application of force (eg, manipulation) to achieve satisfactory alignment of the fracture/dislocation for healing and restoration of limb function.

Key elementRequires achievement of satisfactory alignment for healing and restoration of limb function.

Clinical exampleIncludes manipulation to align fracture or dislocation as part of closed restorative treatment.

inv-08: follow-up within global period — definition of follow-up care within the 90-day global period

DefinitionFollow-up care provided by the same physician during the 90-day global period following restorative fracture treatment.

Global period length90-day global period for fracture follow-up.

Coding implicationIf the same physician provides all follow-up within the 90-day global period, report the appropriate global fracture care code.

OpenPayer

Coding for Closed Treatment of Fractures and Maternity-Related Anesthesia Add-On Billing

Coding and Billing Coverage Criteria

Code Listings and Modifier Guidance

Provider Billing Actions and Operational Rules

Key Definitions

-54	Modifier to indicate only intra-service (operative/restorative) work provided
-55	Modifier to indicate postoperative management only

01967	Anesthesia for management of labor and vaginal delivery
01968	Anesthesia for cesarean delivery (add-on context described)