05/28/2026    Paul Kesselman, DPM

Billing for Fracture Care Post-Urgent Care Visit?

How should I bill for fracture care, after the
patient was seen at Urgent Care or ER? Is the
diagnosis and or CPT code for those patients
different than a patient who comes into me without
first seeking other medical treatment?

Codinghelpline.com Subscriber

Response from Codinghelpline.com:

These are two questions. What is the CPT and ICD-
10. Let's answer the easy part of the question
first:

Assuming this is a new patient to you, the
procedural coding for the proper E/M is would be
dependent on either the complexity level of
medical decision making or time element is for
that E/M. Hence, a CPT 9920X is appropriate for a
new patient.

If the patient is an established patient for a new
problem, then CPT 9921X again, based on medical
decision making and/or time.

Now comes the fun part. The diagnosis.

The patient may be new or established to you and
that determines which set of CPT codes you will
bill.

However, the ICD10 diagnosis will be based on
whether the patient has had treatment prior to
seeing you or not. It is totally independent on
whether or not they patient is new to you or not.

Out of the thousands of examples, let's use a non
displaced closed fracture of the proximal phalanx
of the fifth toe right foot S92.514, this if
billed alone would be returned as incomplete and
non processable because the seventh character is
missing.

The seventh and critical character would denote
where on the time line this patient has received
medical care for their fracture.

If this was an initial encounter for a fracture
(A), subsequent encounter with routine healing (D)
subsequent encounter with delayed healing, G.
subsequent encounter for fracture with non union
(K), subsequent encounter for fracture with
malunion (P).

Hence using the example you cited above, even
though this patient was new to you, the patient
had already sought professional care. Their first
encounter with you was a subsequent encounter for
the fracture. Hence your choice of finishing the
six digit ICD10 with one of the letters above as
appropriate.

Flipping this a bit, lets assume this was an
established patient who is seeking medical care
for the first time for the same fracture. In this
case the "A" character would be the seventh digit.

The above only pertain to closed non displaced
fractures.

There are a whole set of other "root" and seventh
characters for open and/or displaced fractures for
the fifth right toe.

To summarize: It is important to note there are
many determining factors in determining the
correct ICD10 for a fracture. Not only is the code
sequence dependent on the bone. It is equally
important to consider the site on the bone, right
or left, whether the fracture is open, closed,
displaced and where in the treatment cycle this
patient is (have they sought previous care). Hence
lots to consider.

Paul Kesselman, DPM, Oceanside, NY

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