Orthopaedic Fracture Care CPT Coding 2026: The Complete Guide to Global vs. Itemized Billing

Fracture care coding comes down to a single decision made at the first encounter: are you billing the restorative fracture care code with its 90-day global period, or are you billing an E/M visit plus a casting code and itemizing the follow-ups? Both are lawful. Only one is correct for any given patient, and the determining factor is whether the treating provider renders definitive treatment and assumes follow-up care. Get it wrong and you either lose revenue you earned or trigger an NCCI bundling denial. This guide walks the decision tree, the modifier rules, the supply codes Medicare actually pays, and the seven errors that generate most fracture care denials in orthopaedic practices, grounded in the 2026 NCCI Policy Manual, the CMS Global Surgery Booklet, and current CMS coverage articles.

The two lawful methodologies for fracture care

Every fracture encounter resolves into one of two billing methodologies. AAPC's coding education has described them as the global method and the itemization method, and understanding the difference is the foundation of everything else in this guide.

Method 1: The global (restorative) method

You report the fracture treatment CPT code. Closed treatment, closed treatment with manipulation, percutaneous fixation, or open treatment, and, where applicable, the initial E/M with modifier 57 (decision for surgery). The fracture code carries a global period, typically 90 days for definitive fracture care. All routine follow-up care inside that window is included and reported with the no-pay tracking code 99024.

Critically, the initial cast, splint, or strap is included in the fracture care code and is not separately reportable. The 2026 NCCI Policy Manual, Chapter IV, states it twice for emphasis: "Fracture and dislocation CPT codes include the initial casting, strapping, or splinting" (Section G.5), and "CPT codes for closed, percutaneous, or open treatment of fractures or dislocations include the application of casts, splints, or strapping" (Section G.6).

Method 2: The itemization method

You report the E/M visit with modifier 25 plus the casting or strapping code (29000–29799) plus, for Medicare, the casting supply Q code. There is no global period, so every subsequent visit is separately billable as its own E/M.

This is the correct methodology when the provider is not rendering definitive treatment and is not assuming follow-up care, the classic emergency department or urgent care scenario.

The rule that decides between them

NCCI Chapter IV, Section G.7 is the deciding authority, and it is worth committing to memory:

"If a physician treats a fracture, dislocation, or injury with an initial cast, strap, or splint and also assumes the follow-up care, the provider/supplier cannot report the casting/splinting/strapping CPT codes."

And its counterpart, Section G.8:

"If a physician treats a fracture, dislocation, or injury with a cast, splint, or strap as an initial service without any other definitive procedure or treatment and only expects to perform the initial care, the provider/supplier may report an E&M service, a casting/splinting/strapping CPT code, and a cast/splint/strap supply code (Q4001-Q4051)."

Reduced to a single sentence: if you are keeping the patient, bill the fracture code. If you are handing the patient off, bill E/M plus casting plus supply.

The prerequisite most practices miss: stabilization plus a follow-up plan

Before you can use the global method at all, two documentation elements must be present. AAPC's coding guidance on non-operative, non-manipulative fracture care states the condition directly:

"If the provider does not stabilize the bone using a medical supply, or does not indicate a plan for follow-up care, the non-operative, non-manipulative fracture care codes cannot be reported."

This applies to the workhorse non-operative codes an orthopaedic clinic bills constantly: 25600 (closed treatment of distal radial fracture without manipulation), 27786 (closed treatment of distal fibular fracture / lateral malleolus without manipulation), 23500 (closed treatment of clavicular fracture without manipulation).

The practical failure mode: a surgeon sees a nondisplaced distal radius fracture, applies a removable wrist splint, tells the patient to come back in three weeks, and the note reads "nondisplaced distal radius fracture, splint applied, RTC 3 weeks." That is billable under the global method, but only because the splint (stabilization) and the return instruction (follow-up plan) are both documented. Strip either element out of the note and the fracture code is not supportable. Coders reviewing that chart cannot infer a follow-up plan from a scheduling entry; it has to be in the documentation.

Verify per code. Global periods are code-specific. Before you standardize a policy across a fracture code family, confirm the global period for each CPT in the "GLOB DAYS" column of the CMS Physician Fee Schedule Relative Value File. Do not assume every code in a family carries 90 days.

What the 90-day global actually includes (and excludes)

The CMS Global Surgery Booklet (MLN907166, December 2025) defines the package. For a 90-day global, included services are:

• One day of pre-operative care
• Pre-operative visits after the decision to operate
• Intra-operative services
• All other medical and surgical services the surgeon provides during the post-operative period related to the surgery
• Follow-up post-operative recovery visits
• Post-surgical pain management
• Supplies (except specified exclusions)
• Dressing changes and suture removal

Excluded (and therefore separately billable) are:

• The surgeon's initial evaluation establishing the need for major surgery (bill separately with modifier 57)
• Visits unrelated to the surgical diagnosis (modifier 24)
• Diagnostic tests
• Distinct surgical procedures during the post-operative period
• Treatment of post-operative complications requiring a return to the operating room (modifier 78)

Casting and strapping codes: the five NCCI rules that generate denials

The 29000–29799 code family is where most fracture care denials originate, because the rules governing it are counterintuitive. The 2026 NCCI Policy Manual, Chapter IV, Section G lays them out.

Rule 1: The initial cast is bundled into fracture treatment

Covered above. Sections G.5 and G.6. You cannot report both a fracture treatment code and a casting code for the same injury at the same encounter.

Rule 2: You cannot bill removal or repair of a cast you applied

NCCI Section G.1: "The application of external immobilization devices (casts, splints, strapping) at the time of a procedure includes the subsequent removal of the device when performed by the same entity (e.g., physician, practice, group, employees, etc.) Providers/suppliers shall not report removal or repair CPT codes 29700-29750 for those services."

CMS coverage article A53322 puts a finer point on it: "The allowance for application of a cast, splint or strapping includes removal or repair by the same physician or other physician in the same group. Billing for cast removal or repair (29700-29750) should be employed only for casts applied by another physician group."

The word doing the work is group. A partner in your practice removing a cast your surgeon applied is the same entity for NCCI purposes. The 29700–29750 codes exist for the case where a patient arrives from a different practice.

Rule 3: A dressing is not a cast

NCCI Section G.2: "Casting/splinting/strapping CPT codes shall not be reported for application of a dressing after a therapeutic procedure." Post-procedure soft dressings, Ace wraps applied as dressings, and similar are not billable strapping.

Rule 4: No casting code alongside a musculoskeletal procedure on the same anatomic area

NCCI Section G.3: "Casting/splinting/strapping shall not be reported separately if a service from the Musculoskeletal System section of CPT (20100-28899 and 29800-29999) is also performed for the same anatomic area." This sweeps in arthroscopy, open procedures, and injections performed on the same site.

Rule 5: The E/M must be significant and separately identifiable

NCCI Section G.9: "An E&M service, including emergency department E&M, may be reported with a casting/splinting/strapping CPT code if and only if the E&M service is significant and separately identifiable." Modifier 25 is not a formality; the documentation has to carry it.

Supply codes: what Medicare actually pays

This is a small line item that adds up across a busy fracture clinic, and it is one of the most commonly mis-coded elements in orthopaedic billing.

Q4001–Q4051 are separately payable

Per CMS article A53322: "The splints and cast Q codes are considered Level II codes and to be used when supplies are indicated for cast and splint purposes. The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast."

The same article publishes a CPT-to-Q-code crosswalk. For example, 29000–29046 maps to Q4001/Q4002; 29065–29085 maps to the Q4005–Q4016 range; 29305–29515 maps to the Q4025–Q4048 range. Build the crosswalk into your charge capture rather than relying on staff memory.

A4570, A4580, and A4590 have been invalid for Medicare since 2001

This one still appears in orthopaedic charge masters twenty-five years later. CMS Program Memorandum Transmittal AB-01-60 (April 24, 2001) established the Q code range and stated that "Codes A4570, A4580, A4590, L2102, L2104, L2122, and L2124...are invalid for Medicare use effective July 1, 2001, for carrier processed claims." A three-month grace period ran through September 30, 2001. Since October 1, 2001, these codes have been non-payable to Medicare.

Two caveats worth keeping. First, this is a Medicare-specific ruling. Some commercial payers and workers' compensation fee schedules still recognize the A codes, so your payer-specific rules may legitimately differ. Second, under OPPS, cast and splint supplies are handled differently: NCCI Chapter IV notes that for hospitals under OPPS, "Payment for the cast/splint/strap supplies is included in the payment for the procedure reported."

Modifiers: the fracture care set

Modifier 57: decision for surgery

The single highest-yield modifier in fracture care, and the one most often omitted. CMS article A53322 states the consequence directly: "If the decision to have surgery was made by the surgeon on the day before or the day of surgery, a modifier 57 needs to be appended to the evaluation and management code used. Without this modifier, your visit will be denied as included in the global package of the surgery."

When a patient presents with a fracture and the surgeon evaluates, decides on definitive treatment, and renders that treatment the same day, the E/M is separately payable — but only with modifier 57 attached.

Modifiers 54, 55, and 56: split surgical care

These govern the very common orthopaedic scenario where one provider renders the definitive treatment and another manages the follow-up.

• Modifier 54 (surgical care only): the surgeon gave all or part of the post-operative care to another provider.
• Modifier 55 (post-operative management only): a provider other than the surgeon provides post-operative management. Per the CMS Global Surgery Booklet, three requirements attach: the date of surgery is the service date on the claim; providers must keep written transfer agreement copies in the patient's medical record; and the provider accepting care must furnish at least one service before billing.
• Modifier 56 (pre-operative care only): used when a provider furnishes only pre-operative services. Note that Medicare does not recognize modifier 56.

CMS article A53322 walks a worked example: the surgeon performs the procedure with modifier 54; the second physician reports the same CPT code with modifier 55 for follow-up care through the balance of the 90-day global.

The ED handoff: modifier 54 or E/M plus casting?

This is the most consequential judgment call in fracture care, and it is regularly decided wrong.

An emergency department physician who reduces a fracture and casts it has rendered definitive treatment. The correct billing is the fracture care code with modifier 54; the orthopaedist who assumes follow-up reports the same code with modifier 55.

An emergency department or urgent care provider who splints an injury without rendering definitive treatment and refers the patient out has not performed fracture care. Per NCCI G.8, the correct billing is E/M + casting/splinting CPT + Q supply code, not a fracture code with modifier 54. The receiving orthopaedist then bills the fracture care code in full when definitive treatment is rendered.

The hinge is whether definitive or restorative treatment occurred. When your practice receives fracture referrals from EDs and urgent cares, this determination should be made from the referring documentation at intake, not guessed at from the claim.

Modifiers 58, 78, and 79: procedures during the global period

• 58 — staged or related procedure, planned prospectively or at the time of the original procedure. Does not restart the global period.
• 78 — unplanned return to the operating room for a related procedure (e.g., hardware failure, wound complication). Does not restart the global period.
• 79 — unrelated procedure during the post-operative period. A new post-operative period starts.

Modifier 24: unrelated E/M in the global period

When a patient in a 90-day fracture global returns for an unrelated complaint (a new knee problem during a wrist fracture global) the E/M is separately billable with modifier 24 and documentation establishing the unrelated diagnosis.

Modifiers 59 and the X{EPSU} set

CMS's April 2026 guidance (MLN1783722) reiterates the hierarchy. XE = separate encounter; XP = separate practitioner; XS = separate structure, "a service that is distinct because it was performed on a separate organ/structure"; XU = unusual non-overlapping service. CMS's instruction is unambiguous: "Use these modifiers instead of modifier 59 whenever possible. Only use modifier 59 if no other more specific modifier is appropriate."

For orthopaedics, XS is usually the correct modifier when the distinctness is anatomic, two fractures in different extremities, for instance.

RT and LT: laterality

Laterality modifiers apply on fracture codes as they do elsewhere (28450-LT, for example). With ICD-10 increasingly requiring laterality at the diagnosis level as well, mismatches between the CPT laterality modifier and the ICD-10 laterality digit are a growing source of front-end edits.

The seven most common fracture care billing errors

1. Reporting a casting code when the same provider assumes follow-up care. Prohibited by NCCI G.7. This is the single most common fracture care denial in an orthopaedic office setting.
2. Reporting a casting or strapping code alongside a fracture treatment code for the same anatomic area. Prohibited by NCCI G.3, G.5, and G.6, the initial cast is included.
3. Billing 29700–29750 for removal or repair of a cast your own group applied. Prohibited by NCCI G.1 and CMS article A53322.
4. Omitting modifier 57 on the same-day or day-before E/M. Per CMS, the visit "will be denied as included in the global package."
5. Billing a fracture care code without documented stabilization or a documented follow-up plan. Per AAPC guidance, the non-operative, non-manipulative fracture codes cannot be reported in that circumstance.
6. Using A4570, A4580, or A4590 for Medicare casting supplies instead of Q4001–Q4051. Invalid since 2001.
7. Billing a casting code for a post-therapeutic-procedure dressing. Prohibited by NCCI G.2.

Are there 2026 CPT changes to fracture care?

No. The CPT 2026 code set, released by the AMA in September 2025 and effective January 1, 2026, contains 418 total changes: 288 new codes, 84 deletions, and 46 revisions. The changes concentrate in digital health and remote monitoring, AI-enabled diagnostic services (roughly 27% of new codes), Category III codes, hearing devices, and behavioral health telehealth. The one musculoskeletal-adjacent update of note is a comprehensive rework of the Lower Extremity Revascularization section, which deleted the prior codes and introduced 46 new ones.

No CPT 2026 changes to fracture care or casting and strapping codes appear in the AMA's official release or in the 2026 NCCI Chapter IV. If you encounter a blog claiming otherwise, ask for the primary citation.

Frequently asked questions

When should I bill a fracture care code instead of an E/M plus casting?

Bill the fracture care code when the provider renders definitive or restorative treatment and assumes follow-up care. Bill E/M plus casting plus the supply code when the provider furnishes only initial stabilization without definitive treatment and expects the patient to be managed elsewhere. NCCI Chapter IV, Section G.7 prohibits reporting casting codes when the same provider assumes follow-up care.

Can I bill for the cast application when I bill a fracture care code?

No. The initial cast, splint, or strapping is included in the fracture or dislocation treatment code. NCCI Chapter IV states that "fracture and dislocation CPT codes include the initial casting, strapping, or splinting" and that treatment codes "include the application of casts, splints, or strapping." Casting supplies (Q4001–Q4051) may still be separately reported to Medicare in the physician office setting.

Can I bill for removing a cast?

Only if a different physician group applied it. Per NCCI Chapter IV, Section G.1 and CMS article A53322, the allowance for cast application includes removal or repair by the same physician or any physician in the same group. CPT codes 29700–29750 should be used only for casts applied by another practice.

What is the difference between modifier 54 and modifier 55?

Modifier 54 indicates the surgeon provided the surgical care only and transferred post-operative management to another provider. Modifier 55 indicates a provider other than the surgeon is furnishing the post-operative management. Both providers report the same CPT code. Medicare requires that the date of surgery be used as the service date, that a written transfer agreement be documented in the medical record, and that the accepting provider furnish at least one service before billing.

Which supply codes does Medicare pay for casting materials?

Q4001 through Q4051. Payment for these HCPCS Level II codes is in addition to the physician fee schedule payment for the cast or splint application procedure. A4570, A4580, and A4590 have been invalid for Medicare since October 1, 2001, per CMS Transmittal AB-01-60, though some commercial and workers' compensation payers may still recognize them.

Do I need modifier 57 for fracture care?

Yes, when the decision for definitive treatment is made by the surgeon on the day of or the day before the procedure and you are billing the E/M separately. CMS states plainly that without modifier 57 the visit will be denied as included in the global package of the surgery.

What is CPT 99024 and do I have to report it?

99024 is the no-pay tracking code for post-operative visits furnished during a global period, required under Section 523 of MACRA. Note that in the CY2027 Physician Fee Schedule proposed rule, CMS has proposed to pause this data collection requirement as part of a broader re-examination of global surgical package valuation.

Why fracture care coding is a systems problem, not a training problem

Every rule in this guide is knowable, and most orthopaedic coders know them. Fracture care denials persist anyway, because the decision that drives everything (global versus itemized) is made in a clinic room by a surgeon who is not thinking about NCCI Chapter IV, and is then reconstructed downstream by a coder reading a note that may or may not contain the two elements (stabilization, follow-up plan) the methodology requires.

The gap is not knowledge. It is the distance between the encounter and the coding decision, and every day of that distance is a day the documentation cannot be improved because the patient has gone home.

Closing it means moving the coding decision upstream, into the encounter itself. An autonomous coding agent operating inside the EHR reads the note as it is written, recognizes that a fracture code was selected without a documented follow-up plan, and surfaces that gap while the surgeon is still in the chart. It applies modifier 57 when the decision-for-surgery language is present. It blocks a casting code when a fracture code for the same anatomic site is already on the claim. Maia's AutoCoder reports a 30% efficiency gain and a significant revenue lift doing exactly this work for orthopaedic groups across the country.

See how Maia's AutoCoder handles this automatically for orthopaedic practices. Book a demo at usemaia.com.