ABOUT FRACTURE AND SURGERY CHARGES
Physician's and other medical providers are required to bill according to insurance regulations which are established and monitored by the Insurance Commission and the government. This is often confusing to patients and understanding the guidelines that are to be followed will assist you in understanding the charges you have for services provided.
CPT CODES: Physicians bill using CPT codes. These are numbers which have been assigned to describe different types of treatment that patients receive. Physicians are REQUIRED to bill according to the CPT guidelines which have been established. These codes are divided into different categories:
- Evaluation & Management which covers routine office visits
- Surgical Codes which include surgery, fracture care and injections
- Radiological Codes which include charges for x-rays, MRI's, CT Scans
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Laboratory Codes which covers blood work ordered by your physician
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Drug Codes - Durable Medical Equipment which covers the medications you are provided and things such as braces, splints, crutches, ace bandages, etc.
The fracture or surgery for which you have been treated falls under the surgical codes. This does not necessarily mean that surgery was performed but that the insurance guidelines require the physician to bill for this service as "global days." Global days are days that have been assigned to a particular type of treatment where the physician must see the patient for the same injury without charging the patient additional charges for his services (Professional fees) as long as the treatment is related to the original injury and no complications have occurred. The number of global days for follow up varies by the type of surgery or fracture but is normally 90 days. Charges for other services are still billed during the global period. These may include:
- Cast changes - slings - splints - braces
- Other supplies
- X-rays
- New injuries, repeat procedures due to complications
- Treatment not related to the original fracture or surgery
Each CPT code is assigned a charge amount. These are based on the medical expertise required and the average of the cost for treating the particular injury or service. In some instances a fracture or surgery patient may only require minimum treatment and does well, however another patient with the same injury may require extensive treatment. Since we must bill by CPT codes and we cannot vary the charge amounts, an average is used for all CPT codes. These amounts are reviewed on a yearly basis and compared to those of other providers. Our rates are based on the average cost to provide the service and average charges of other orthopaedic practices.
WHEN YOU HAVE A FRACTURE OR SURGERY - YOU WILL BE BILLED FOR THE FOLLOWING:
- The initial office or emergency room visit (E&M Code) This charge covers the physician taking your medical history and reviewing information provided by you and other physicians. This is normally done before he comes into the room to begin treatment.
- Fracture Charge (Surgical Procedure) This charge covers the physician's fee for treating the fracture. The physician may or may not have to align the fracture and may or may not have to take you to surgery. Remember each CPT code covers the type and extent of treatment being performed and the physician's charges for follow up treatment for the fracture during the global period, 30-60-90 days, as long as the treatment is for continued care of the original injury.
- X-rays if additional x-rays are taken in the office we will bill for the x-rays taken. If you bring x-rays from another facility the physician will review these and no charge will be made.
- Supplies Charges for things such as braces, slings, ace bandages, suture trays and other items are billed separately. Please note charges for cast changes due to patient request are not covered by your insurance. Some of the equipment you may receive is provided and billed through a third party, Orthoscript, which is not affiliated with COA.
We hope this will answer any questions you may have. However, if you have any other questions, please call our office and we will be glad to assist you.