A family physician who runs a walk-in clinic asked us to settle an argument. Her coder insisted that every wrist fracture she splinted should be billed with a global fracture care code, because "that is what orthopedists do." Her office manager insisted on an office visit plus a splint code, because half of those patients were referred to orthopedics the same week. They had been alternating between the two depending on who was at the desk, and the payers had noticed: the practice had a stack of denials for follow-up visits that fell inside a global period it had created without meaning to.
Both were half right. CPT allows a closed fracture treated without manipulation to be coded either as global fracture care or as an evaluation and management (E/M) visit plus a cast or splint application. Neither is a trick. They describe different arrangements of the same clinical work, and the correct one depends on who is actually managing the fracture through healing. Choosing well is a coding decision; choosing consistently is a policy decision; choosing randomly produces the stack of denials.
This article covers fracture care coding for the office and urgent care setting: what the global codes include, what the E/M plus casting path includes, the modifiers each requires, a worked example with a distal radius fracture, and the six errors we see most often in audits.
Key takeaways
- Global fracture care codes (for example 25600 for a closed distal radius fracture without manipulation) carry a 90-day global period that includes the initial cast or splint, routine follow-up visits and cast removal, but not X-rays, casting supplies or replacement casts.
- The alternative is an E/M visit with modifier 25 plus a cast or splint application code (29075, 29125, 29405, 29515 and others) and supplies, with each follow-up visit billed as its own E/M.
- Global fracture care is appropriate when the practice assumes responsibility for the fracture through healing; E/M plus casting fits when the patient is stabilized and referred, or when definitive care will happen elsewhere.
- The E/M on the day the decision is made to provide global fracture care takes modifier 57; when one physician stabilizes and another manages, modifiers 54 and 55 split the global code between them.
- The most expensive error is billing a global code and then billing follow-up E/M visits inside the 90 days, which payers deny and auditors recoup.
What the global fracture care codes include
The musculoskeletal section of CPT lists closed treatment codes for nearly every bone, with and without manipulation: 25600 for the distal radius without manipulation and 25605 with manipulation, 27786 for the lateral malleolus, 28470 for a metatarsal, 26720 for a finger phalanx, 23600 for the proximal humerus. "Closed treatment" means the fracture site is not surgically opened; "without manipulation" means no reduction was performed. These are surgical codes, and CMS assigns them a 90-day global period.
The global package covers the initial application of the cast, splint or strap; the routine post-treatment visits during the 90 days, including cast checks and the removal visit; and the clinical decision making at those visits. It does not cover the radiographs (73100 for a two-view wrist, 73110 for three views, billed separately each time), the casting and splinting supplies (Q4001 to Q4051 for Medicare, A4570 and A4580 to A4590 for many other payers), or the replacement of a cast or splint during the global period. CPT is explicit that cast and splint reapplication codes may be reported when a cast is replaced during or after the follow-up period, so a cast change at week three is 29075 with the supply code, even inside the 90 days.
Because the global codes are major procedures in Medicare's terms, the E/M service on the day the physician decides to provide fracture care, or the day before, is separately reportable with modifier 57 (decision for surgery). This is the modifier most office practices forget; without it the E/M is bundled into the global and denied. Modifier 25 is for minor procedures with 0- or 10-day globals, which is why it belongs on the E/M plus casting path and not here.
The E/M plus casting alternative
The other legitimate path treats the visit as an evaluation and management service with a separately identifiable procedure. The physician bills the E/M (99203 or 99213, for example) with modifier 25, plus the application code for what was applied: 29075 short arm cast, 29085 hand and lower forearm cast, 29105 long arm splint, 29125 short arm splint (static), 29130 finger splint (static), 29405 short leg cast, 29505 long leg splint, 29515 short leg splint, 29540 strapping of the ankle. Casting codes have a 0-day global, so there is no package and no 90-day shadow. Supplies are billed the same way as in the global path.
Every subsequent visit is then billed on its own merits: an E/M for the recheck, an X-ray if taken, a reapplication code if the cast or splint is changed. This path fits when the practice is stabilizing the injury and sending the patient to orthopedics, when the fracture will be treated with a removable splint and minimal follow-up, or when the patient is unlikely to return.
| Element | Global fracture care (e.g. 25600) | E/M plus casting |
|---|---|---|
| Day-one claim | E/M with modifier 57, 25600, X-ray, supply code | E/M with modifier 25, 29125 or 29075, X-ray, supply code |
| Follow-up visits within 90 days | Included; not separately billable unless unrelated (modifier 24) | Each visit billed as an E/M |
| Cast or splint change | Reapplication code plus supply, separately billable | Reapplication code plus supply, separately billable |
| X-rays at follow-up | Separately billable | Separately billable |
| Who should use it | The physician or group managing the fracture to healing | The physician stabilizing and referring, or providing limited follow-up |
| Split care | Modifier 54 (treatment only) and 55 (post-treatment management only) | Not applicable |
Which one is right
The deciding question is whether your physician is providing the definitive, restorative treatment of the fracture and the follow-up that goes with it. The American Academy of Orthopaedic Surgeons and the AMA have both described the closed treatment codes as fracture management, not as a fee for putting on a splint. If the plan in the note is "splint applied, referred to orthopedics for fracture care," the practice has not assumed that management, and billing 25600 creates two problems: the orthopedist will bill the same code and one of them will be denied as a duplicate, and any follow-up your practice does provide will fall inside a global you should not have opened.
When a hand-off is planned from the start, the cleaner arrangement is the 54/55 split. The urgent care or emergency physician bills 25600-54 for the treatment portion (the assessment, the decision, the initial immobilization) and the orthopedist bills 25600-55 for the post-treatment management. Payers pay a set percentage of the global fee for each modifier, the two claims do not conflict, and the follow-up visits are properly inside the orthopedist's package. The transfer of care should be documented in both charts, with the date the orthopedist assumed care.
Consistency matters as much as the choice. Write down the rule: global fracture care when we manage to healing and see the patient at least twice more; E/M plus casting when we refer or expect one follow-up or none. Then apply it every time.
A worked example: a distal radius fracture
A 34-year-old falls on an outstretched hand and comes to the clinic. Two-view wrist X-rays show a nondisplaced distal radius fracture. The physician performs a detailed evaluation, confirms neurovascular status, applies a short arm splint and plans a cast at the one-week visit once swelling settles, with follow-up at three and six weeks and a final X-ray. The physician will manage the fracture personally.
Under global fracture care, the day-one claim is 99203-57, 25600, 73100, and the splint supply code. Week one: a cast is applied, billed as 29075 plus the cast supply, with no E/M because the visit is routine post-treatment care inside the global. Week three: X-ray 73100 and a cast check, no E/M. Week six: X-ray, cast removal, no E/M. If the patient comes in at week four for an unrelated sinus infection, that visit is 99213-24, because modifier 24 identifies an unrelated E/M during a postoperative period.
Under E/M plus casting, the same course is 99203-25, 29125 and the splint supply on day one; 99213-25, 29075 and the cast supply at week one; 99213 and 73100 at week three; and 99213 and 73100 at week six. Both sequences are correct for this patient. Which pays more depends on the payer's fee schedule and how many follow-ups actually happen. The point is not to pick the richer one after the fact; the documentation on day one says which arrangement you chose, and the rest of the claims follow it.
The six errors we find in audits
- Global code billed, then follow-up E/M visits billed inside the 90 days without modifier 24 and without an unrelated diagnosis. These deny with the global period reason code, and when they pay, they are recouped later.
- Initial cast application billed (29075) on the same day as the global code. The first cast is included in 25600; only replacements are separate.
- No modifier 57 on the day-one E/M with a global code, so the visit is bundled and lost.
- Global code billed by a practice that referred the patient out the same day, producing a duplicate with the orthopedist's claim.
- Casting supplies never billed, or billed with the wrong payer's code set (Q codes to a commercial payer that wants A codes, or the reverse).
- Manipulation codes (25605) billed when the note describes no reduction, or the reverse, a reduction performed and documented but the "without manipulation" code chosen from habit.
Fixing these is mostly a template problem. A fracture note that forces the physician to record "assuming fracture care through healing: yes or no" answers the coding question at the point of care, and a charge sheet that lists supply codes beside casting codes fixes the fifth error on its own. Our coding courses use fracture care to teach global periods because it exercises modifiers 24, 25, 54, 55 and 57 in one story, and our audit team checks these six items on every orthopedic and urgent care review.
Questions we hear
Can we bill the global code if the patient never comes back?
You can bill for the care you intended and documented, but if patients rarely return, the global code is describing follow-up you are not providing, and a payer reviewer will read it that way. Practices with high no-return rates are usually better served by the E/M plus casting path.
What about a buckle fracture treated with a removable splint and one recheck?
Many practices code this as E/M plus splint application, on the reasoning that a removable splint with a single recheck is not the restorative treatment the global code describes. Others bill the global. Either can be defended if documented consistently; what cannot be defended is the global code plus a billed recheck.
Does the 90-day global block us from billing for a new fracture in the same arm?
No. A new injury is a new fracture, billed with its own code and modifier 79 (unrelated procedure during the postoperative period) if it falls inside the earlier global. The note should make clear it is a new event with a new mechanism of injury.
What to do this week
- Pull the last six months of claims with codes 25600, 27786, 28470 or other closed treatment codes and check whether any follow-up E/M was billed inside the 90 days without modifier 24.
- Check the same claims for a day-one E/M with modifier 57; add the modifier and rebill within the payer's window where it was missing.
- Write a one-paragraph practice rule for when you use global fracture care and when you use E/M plus casting, and put it in the coding manual.
- Add a required "assuming fracture care through healing" field to the fracture note template.
- List the casting supply codes by payer on the charge sheet next to the 29000-series codes.
- Where patients are routinely referred to orthopedics, contact the receiving group about using the 54/55 split and documenting the transfer date.
