Glossary · Clinical

Fracture

A fracture is a break in the continuity of a bone, ranging from a hairline crack to a complete structural disruption. In orthopedic coding, the fracture type, displacement status, treatment method, and treating provider's scope of care all drive code selection.

Verified May 8, 2026 · 9 sources ↓

Drawn from CMSAAPCAaomsAskphc

Definition

Source · Editorial summary grounded in 9 cited references ↓

A fracture occurs when a bone is subjected to force or stress that exceeds its structural tolerance, resulting in a partial or complete break. Fractures are classified along several axes that directly affect both clinical management and coding: open versus closed (whether the skin is breached), displaced versus nondisplaced (whether bone fragments have shifted from anatomic alignment), and descriptive pattern terms such as comminuted (shattered into multiple fragments), transverse, oblique, spiral, or compression. For vertebral fractures specifically, the mechanism—osteoporotic, traumatic, or malignant—further shapes both treatment options and coverage criteria.

Treatment falls into two broad categories. Closed treatment means the fracture site is not surgically exposed. It may be performed without manipulation (e.g., casting or splinting to provide comfort and stability), with manipulation (physically reducing displaced fragments), or with traction. Open treatment and percutaneous skeletal fixation represent operative options when closed methods are insufficient. The chosen treatment method is the primary determinant of which CPT code family applies; anatomy (specific bone) and displacement status refine the selection within that family.

From a billing standpoint, fracture care typically carries a 90-day global surgical period. The global period bundles the initial encounter, all follow-up visits, and cast or splint changes by the same physician group. Providers can alternatively bill itemized services when no definitive fracture care procedure is rendered—for example, when treating a nondisplaced fifth metatarsal fracture that requires only a protective splint and observation without a formal treatment plan anchored to a global code.

Why it matters

Assigning the wrong fracture care code—or mixing global and itemized billing within the same episode—triggers claim denials, overpayment demands on audit, and potential NCCI edit rejections. Specifically: billing a closed-treatment-without-manipulation CPT code when only a temporary stabilization splint was applied inflates the global period and bundles follow-up visits that should be separately payable; failing to append modifier 54 when the treating surgeon will not provide postoperative care leaves the accepting physician unable to bill modifier 55 for that care; and under-coding an open fracture as closed can create medical-record-to-claim discrepancies that flag on RAC audits. For vertebral compression fractures, coverage under CMS LCD L38213 and L38737 hinges on documented failure of conservative care, fracture acuity on advanced imaging, and pain severity—without that documentation, vertebroplasty and kyphoplasty claims are denied regardless of code accuracy.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Applying a global fracture care CPT code when only a temporary stabilization splint was used for comfort—casting or splinting alone does not constitute 'closed treatment' under current CPT definitions unless it is the definitive management plan.
Omitting modifier 54 (Surgical Care Only) when the initial treating provider hands off postoperative management; the accepting provider cannot then bill modifier 55 without the corresponding 54 on the original claim.
Billing separate fracture care codes for multiple fractures of similar adjacent bones (e.g., multiple metatarsals of the same foot) when NCCI policy requires only one unit of service for closed treatment without manipulation across those bones.
Conflating open fracture (skin breach) with open treatment (surgical exposure); ICD-10-CM laterality and open/closed qualifiers must match the operative report exactly to avoid audit flags.
Failing to append modifier 57 (Decision for Surgery) to the E/M service rendered on the same day as the decision for operative fracture treatment, or incorrectly using modifier 25 instead of 57 for major procedures with a 90-day global.
Billing cast removal codes (29700–29750) when the cast was applied by the same physician group—removal and repair by the same group is already bundled into the global fracture care fee.
Not documenting failure of conservative care before submitting vertebroplasty or kyphoplasty claims for vertebral compression fractures; CMS LCDs L38213 and L38737 require evidence that non-operative management was tried and insufficient.

Related codes

Codes commonly involved when this concept appears in practice.

CPT

Modifiers

57 Decision for surgery 25 Significant separately identifiable E/M 22 Increased procedural services 59 Distinct procedural service LT Left side RT Right side 50 Bilateral procedure

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 9 cited references ↓

01What is the difference between closed treatment with and without manipulation?

Without manipulation means the fracture is managed by immobilization alone—cast, splint, or strapping—because the bone fragments are acceptably aligned. With manipulation means the provider physically reduces displaced fragments before immobilizing the limb. The two approaches map to different CPT codes and typically carry different reimbursement rates, so the operative or office note must clearly state whether reduction was attempted and achieved.

02When should fracture care be billed globally versus itemized?

Bill globally when the physician renders a definitive treatment procedure (e.g., applies a cast with a treatment plan) and will manage the follow-up within the 90-day global period. Bill itemized—separate E/M plus supply codes—when no formal fracture care procedure is performed, such as for a minimally displaced fracture managed with activity modification and observation only. Payer rules vary, so confirm global vs. itemized preferences with each payer before finalizing the claim.

03Does applying a splint in the ED always constitute fracture care?

No. If the splint is applied only to temporarily stabilize the fracture for patient comfort pending follow-up with a specialist, it does not meet CPT's definition of closed treatment. In that scenario, the ED provider should bill the appropriate E/M code plus the splint supply code, not a global fracture care CPT. The definitional shift codified in 2022 CPT updates clarified this boundary explicitly.

04What modifiers are required when two different physicians share fracture care?

The physician who performs the initial procedure but will not provide postoperative care appends modifier 54 (Surgical Care Only) to the fracture care CPT. The physician accepting ongoing postoperative management bills the same fracture care CPT with modifier 55 (Postoperative Management Only). The accepting physician receives approximately 20 percent of the global fee. Both providers must document the transfer of care in the medical record.

05How does NCCI affect billing when a patient has fractures of multiple adjacent bones?

NCCI policy limits providers to one unit of service for closed-treatment-without-manipulation codes when a single cast or splint treats fractures of multiple similar bones at the same anatomic site—for example, two metatarsals of the same foot. Billing separate units or separate codes in this scenario will trigger a Medically Unlikely Edit (MUE) denial. If the fractures are genuinely distinct and involve different anatomic regions or require separate procedures, modifier 59 or an X-modifier may be appropriate, provided documentation supports the distinctly separate services.

06What documentation is required for Medicare to cover kyphoplasty or vertebroplasty for a vertebral compression fracture?

CMS LCD L38213 and L38737 require documentation of: an acute vertebral compression fracture confirmed on advanced imaging (MRI preferred), significant pain that has not responded adequately to conservative management such as bed rest and analgesics, and the absence of contraindications to cement augmentation. The clinical note should reflect pain severity, functional limitation, and the duration and nature of prior conservative treatment. Missing any of these elements is the most common reason PVA claims are denied on review.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

When Mira detects fracture-related documentation, it checks four variables before suggesting a code path: 1. TREATMENT TYPE — Did the physician render definitive fracture care (closed without manipulation, closed with manipulation, open, or percutaneous fixation), or only a temporary stabilization splint? If the note describes splinting solely for comfort pending specialist referral, Mira flags itemized billing (E/M + splint supply code) rather than a global fracture care code. 2. GLOBAL vs. ITEMIZED — If the physician documents a definitive treatment plan and will manage follow-up, Mira defaults to the global fracture care CPT. If the physician explicitly states no further follow-up will be provided, Mira prompts modifier 54 on the fracture care code and alerts the accepting provider to bill modifier 55. 3. MODIFIER LOGIC — For same-day E/M + major fracture care, Mira applies modifier 57 (Decision for Surgery) to the E/M, not modifier 25. For minor procedures (90-day global not triggered), modifier 25 is appropriate on the E/M. 4. VERTEBRAL COMPRESSION FRACTURES — When VCF with vertebroplasty or kyphoplasty is documented, Mira checks the note for (a) duration of conservative management, (b) advanced imaging confirmation of acute fracture, and (c) pain severity—all three are required to satisfy CMS LCD criteria under L38213/L38737. Missing elements generate a documentation gap alert before claim submission. NCI PTP edit awareness: Mira flags same-encounter billing of multiple closed-treatment-without-manipulation codes for ipsilateral similar bones and suppresses duplicate units per NCCI Chapter 4 guidance.

See Mira's approach

Related terms

Kyphoplasty Clinical

Kyphoplasty is a minimally invasive percutaneous vertebral augmentation procedure in which a mechanical device creates a cavity inside a fractured vertebral body before bone cement is injected—distinguishing it from vertebroplasty, which skips the cavity-creation step.

Vertebroplasty Clinical

Vertebroplasty is a minimally invasive, image-guided procedure in which bone cement (typically polymethyl methacrylate, PMMA) is injected percutaneously into a fractured vertebral body to stabilize the fracture and reduce pain. It is distinct from kyphoplasty, which first creates a cavity with an inflatable balloon before cement injection.

Comminuted fracture Clinical

A comminuted fracture is one in which the bone is shattered into three or more fragments at the fracture site. It typically results from high-energy trauma and requires precise documentation of displacement status, anatomic location, and laterality to support accurate ICD-10-CM coding and appropriate treatment-level CPT selection.