One broken wrist can produce claims from three different providers: the emergency or urgent care physician who sees it first, the orthopedist who treats it, and sometimes a second clinician who manages the follow-up. All three draw on the same 90-day fracture care package, so fracture care coding decides whether each one gets the right code, modifier and share.
Fracture care coding starts with one rule: these are surgical codes, even when the physician makes no incision. That single fact explains why the global package, modifiers 54 and 55, and the decision-day modifier 57 matter so much to who gets paid, and how much.
Fracture Care Coding by Treatment Level
Most fracture code families step up in three levels, and the level depends on what the physician actually did. For example, a distal radius fracture shows the pattern:
- Closed treatment without manipulation (25600): the physician immobilizes the fracture in a cast or splint as definitive care, with no reduction.
- Closed treatment with manipulation (25605): the physician realigns the bones without an incision, then immobilizes them.
- Percutaneous or open fixation (25606, 25607–25609): the surgeon places pins, plates or screws.
All three are fracture care codes with a 90-day global period. A temporary splint applied only for comfort or transport is not closed treatment, so it takes a different code, as shown below. For other code families, see our orthopedic surgery coding cheat sheet.
What the 90-Day Fracture Global Covers
The CMS global surgery booklet defines what one fracture care payment includes and what practices can still bill.
Included in the fracture care code
- The visit on the day before or day of treatment, once the physician decides to treat
- Reduction or immobilization itself, including the first cast or splint
- Routine follow-up visits for 90 days
- Cast or splint removal and post-treatment pain management
Billed separately during the global
- The first visit that leads to the decision to treat, with modifier 57
- Unrelated problems, with modifier 24
- X-rays and other diagnostic tests
- Replacement casts or splints after the first one
- A return to the operating room for a complication, with modifier 78, or a planned or more extensive procedure, with modifier 58
In fracture care coding, most denials come from billing a routine follow-up visit that the global already paid for.
Restorative vs Definitive Care in the ED and Urgent Care
The first provider to see a fracture must decide whether they are giving temporary, restorative care or starting definitive treatment. The ACEP fracture management FAQ puts it simply: report either the splint code or the fracture care code, never both.
| What the first provider does | What to bill | Who bills follow-up |
|---|---|---|
| Temporary splint for comfort, refers to orthopedics | E/M plus splint code (29xxx) | Orthopedist bills the full fracture care code |
| Reduces the fracture, then refers | Fracture code with modifier 54 | Orthopedist bills the same code with modifier 55 |
| Treats and follows the patient | Full fracture care code | Same provider, inside the global |
Also, urgent care centers follow the same logic. For more on that setting, see our guide to urgent care coding.
Splitting the Global: Modifiers 54 and 55
When one provider treats the fracture and another manages the follow-up, both bill the same fracture code and divide the payment. Medicare expects modifier 54 whenever the treating provider will not deliver the post-treatment care, whether the providers formally document the transfer or simply expect it.
- Treating provider: bills the fracture code with modifier 54 on the date of treatment.
- Receiving provider: bills the same code with modifier 55 only after seeing the patient at least once, using the original treatment date as the date of service.
- Both: record the transfer date and keep a copy of the transfer agreement in the chart.
- Payment: each modifier pays its share of the global, and the two together cannot exceed what one provider would have received.
As a result, a missing 55 claim is one of the most common revenue gaps for orthopedic groups that take ED and urgent care referrals. Our article on orthopedic coding modifiers covers the related modifiers 58 and 78.
Modifier 57 or 25 on Decision Day
Practices can bill the visit where the physician decides to treat a fracture separately, but the modifier depends on the global period. Fracture care codes carry a 90-day global, which makes them major procedures, so the decision-for-treatment E/M on the same day or the day before takes modifier 57.
Modifier 25 is for a significant, separately identifiable problem managed at the same visit, such as a head injury evaluated alongside the fracture. A visit that only examines the injury and reviews the X-ray before treatment is the decision visit and uses 57, not 25. Medicare does not accept 57 on procedures with a 0- or 10-day global.
Casting and Splinting Inside and Outside the Global
Casts and splints are the part of fracture care coding where practices most often overbill or underbill. Here is what is included and what is paid separately:
- First cast or splint: included in the fracture care code.
- Replacement casts or splints: billable during the global with the 29xxx application code.
- Casting supplies: in the office, Medicare pays splint and casting supplies (Q4001–Q4051) separately, in addition to the application code, and many commercial payers do the same.
- Prefabricated splints: a simple off-the-shelf splint often falls inside the E/M; however, custom or prefabricated orthoses may qualify as DME with L-codes when the payer allows. Our guide to orthopedic bracing billing covers those rules.
- Restorative splint only: when the provider bills no fracture care code, the 29xxx code and supplies are the procedure.
From First Visit to ORIF: Three Scenarios
These three cases show how fracture care coding rules apply, from a simple office cast to a surgical conversion during the global.
Non-displaced fracture treated in the office
An orthopedist sees a patient with a non-displaced distal radius fracture and applies a cast. Bill the E/M with modifier 57, 25600 for closed treatment without manipulation, and casting supplies where the payer pays them. The global includes follow-up visits for 90 days; however, the practice bills a replacement cast in week four separately.
ED reduction, orthopedic follow-up
The ED physician reduces a displaced fracture and splints it, then refers. In this case, the ED bills the E/M with modifier 57 and 25605 with modifier 54. The orthopedist bills 25605 with modifier 55 after the first follow-up visit, using the ED date of service. However, the orthopedist does not bill that first visit as a separate E/M.
Closed treatment that converts to ORIF
A fracture treated with closed reduction slips, and two weeks later the same orthopedist performs open fixation. Bill the ORIF code with modifier 58, because the Medicare Claims Processing Manual allows 58 for a procedure that is more extensive than the original. A new 90-day global starts with the ORIF.
Conclusion: Get Paid for Every Stage of Fracture Care
Fracture care is one of the few areas where several providers share a single payment, and where a missing modifier can leave one of them unpaid entirely. The questions are always the same: was the first treatment restorative or definitive, who is managing the 90-day follow-up, and was the decision visit a 57 or a 25? Answer them in the record, and every claim in the episode follows.
Orthopedic groups, urgent care centers and emergency physician groups often see the same denials repeat across these handoffs. MBW RCM reviews fracture claims across all three settings, matching 54 and 55 pairs and tracking global periods through its orthopedic billing and coding services.
Fracture Care Coding FAQs
Is fracture care a surgical global package?
Yes. Fracture care codes are surgical codes with a 90-day global period, even when there is no incision.
When should an ED physician use modifier 54 on fracture care?
When the ED physician provides definitive treatment, such as a reduction, but another provider will manage the follow-up. In contrast, a temporary splint alone takes a splint code, not a fracture care code.
Can a provider bill modifier 55 before seeing the patient?
No. The provider taking over care must see the patient at least once before billing with modifier 55.
Is the initial cast billable with a fracture care code?
No. The fracture care code includes the first cast or splint. However, replacement casts during the global period are billable separately.
Which modifier applies to the decision to treat a fracture?
Modifier 57, because fracture care codes are major procedures with a 90-day global.