Should a patient visit for a fracture be billed as a low or moderate visit?

Billing for Fracture Care: Low vs. Moderate Visit

Fracture visits should be billed as moderate complexity visits due to the comprehensive assessment and management required for these injuries.

Rationale for Moderate Complexity Billing

The American Academy of Orthopaedic Surgeons (AAOS) guidelines for fracture management indicate that fracture care involves multiple components that justify moderate complexity billing 1, 2:

1. Comprehensive Assessment Requirements:

   • Evaluation of fracture characteristics (displacement, angulation, comminution)
   • Assessment of post-reduction parameters (radial shortening, dorsal tilt, intra-articular displacement)
   • Determination of stability and need for surgical intervention

2. Decision-Making Complexity:

   • Surgical vs. non-surgical management decisions
   • Consideration of patient-specific factors (age, functional demands)
   • Evaluation of associated injuries and complications

3. Treatment Planning:

   • Development of appropriate immobilization strategy
   • Determination of weight-bearing status
   • Planning for follow-up care and rehabilitation

Clinical Guidelines Supporting Moderate Complexity

The AAOS guidelines specifically note that fracture management requires detailed clinical decision-making 1, 2:

• For patients under 65 years, operative treatment decisions must consider multiple radiographic parameters:

  • Post-reduction radial shortening >3mm
  • Dorsal tilt >10 degrees
  • Intra-articular displacement >2mm

• For patients over 65 years, different treatment algorithms apply, requiring age-specific assessment

Billing Considerations for Fracture Care

Research on fracture care billing demonstrates that appropriate coding significantly impacts patient follow-up and outcomes 3:

• Global fracture care billing (which assumes moderate complexity) results in more comprehensive management
• Patients with itemized billing (often used for low complexity) have significantly more follow-up visits (2.3 vs 1.3 visits)
• Appropriate initial billing classification ensures proper resource allocation for fracture management

Documentation Requirements for Moderate Complexity

To support moderate complexity billing for fracture care, documentation should include:

1. Detailed History:

   • Mechanism of injury
   • Timing of injury
   • Associated symptoms

2. Comprehensive Examination:

   • Neurovascular status
   • Joint stability assessment
   • Soft tissue evaluation

3. Medical Decision Making:

   • Interpretation of radiographic findings
   • Risk assessment for complications
   • Treatment options considered

4. Management Plan:

   • Specific immobilization technique
   • Follow-up schedule
   • Rehabilitation protocol

Special Considerations

For certain fracture types, the complexity is inherently higher, further supporting moderate complexity billing:

• Hip fractures in elderly patients require interdisciplinary care and careful surgical timing (24-48 hours) 1
• Vertebral fractures necessitate evaluation for osteoporosis and future fracture risk 1
• Pediatric fractures require age-specific assessment protocols 1

Conclusion

Based on AAOS guidelines and clinical evidence, fracture care should be billed as moderate complexity due to the comprehensive assessment, detailed decision-making, and complex management planning required for these injuries. This billing level appropriately reflects the clinical work involved in proper fracture management and ensures adequate resources for optimal patient outcomes.