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November 4, 2011
You fractured your right wrist. You came to the doctor, had x-rays and they put on a cast. You will need to wear your cast for 6 weeks. You are asked to come back in two weeks for a checkup. In the mean time, you receive a notice from your insurance carrier that the provider has billed for a surgery! You think-“There was no surgery! I did not go to the Operating Room; they just put a cast on.” So at your next visit you question the staff on why they billed for surgery…. This is the reason why. Your insurance company requires that we bill our services using a coding system known as CPT (Current Procedural Terminology). The codes used to describe the services we did for you are found in the surgery section of the CPT workbook. This does not mean we are implying that you had an operation. Each bone is listed and there are several variations in selecting the right code. It could be that you did need to go to the operating room and have the bone “reduced” (which means put back into the right alignment). Or it could be that your care only required casting to maintain the correct alignment while the bones heal. Either way is considered a surgery by the code book. According to CPT guidelines, fracture care is billed as a packaged service. This means that at the time of initial care, a bill is generated that includes: 1. Fracture Care and a trip to the Operating room if required. 2. The first cast or splint application. 3. 90 days of normal, uncomplicated follow-up care. The things that are not included in the package are: 1. X-rays 2. All casting supplies (including those used in the first cast or splint) 3. Any replacement of cast application. 4. The evaluation and management of any additional problems or injuries. 5. The treatment of complications. There will be a separate charge for these. Healthcare billing can be confusing. Do not hesitate to ask questions from your provider or their staff. Also, remember to use your insurance carrier’s member services team to help you understand your specific benefit plan. | 
