Fractures, dislocations, casts and splints

Where you are

Fracture coding connects two records: the diagnosis of the injury and the treatment actually performed. A fracture is a broken bone. A dislocation is displacement of a joint from its normal relationship. The diagnosis describes the injury; the procedure describes the clinician's work.

Begin with the injured site and laterality, then read the treatment report and follow-up plan. Keep the current musculoskeletal introductory instructions open. Do not select a procedure from the injury diagnosis alone.

Injury type and treatment type are separate

The AMA's public explanatory update distinguishes an open or closed injury from open, closed or percutaneous treatment. A closed fracture can receive open treatment. Temporary immobilization solely for comfort does not by itself establish closed fracture treatment. Verify the current full definitions in your authorized book. [fracture-update-ama, pages 1–2]

Build two columns: “injury description” and “treatment performed.” If the diagnosis says closed fracture, record that in the first column. If the operative note describes surgical exposure and repair, record those actions in the second. Do not change the documented injury into an open injury just because an operation occurs.

The full open-treatment definition includes situations beyond directly exposing the fracture at its site. Percutaneous fixation also has its own definition. Record the exposure, visualization and fixation route rather than deciding from incision size or the word “pin.” [fracture-update-ama, page 2]

Manipulation needs actual work

Read whether alignment was actively restored, how that was done and which treatment was completed. A cast can be used with different treatment pathways; its presence alone does not establish manipulation. The current entry distinguishes treatment with and without the relevant work.

Original fictional comparison: one patient receives documented closed treatment without manipulation and planned follow-up. Another patient undergoes a documented reduction before immobilization. The two notes should not be treated as identical merely because both patients leave with a cast.

Now add a third record: a clinician provides only temporary comfort immobilization and refers the patient for treatment elsewhere. Determine what service was actually furnished rather than assuming every initial splint represents the full fracture-treatment service. [fracture-update-ama, page 2; ncci-musculoskeletal-2026, G.7–9]

The first cast is often included

Medicare NCCI includes initial casting, splinting or strapping in fracture and dislocation treatment. Do not add a separate application procedure for that included immobilization. The rule concerns the relationship to the treatment, not whether a cast has its own entry elsewhere in the book. [ncci-musculoskeletal-2026, G.5–7]

A fictional surgeon completes fracture treatment and applies the first cast to stabilize the same site. A proposed second line for that application requires rejection under the cited inclusion. Keep supply reporting separate from the application service; a supply rule does not make an included application separately reportable.

A dressing after a therapeutic procedure is not automatically a cast, splint or strapping service either. Identify the actual device and work instead of translating any bandage into an immobilization procedure. [ncci-musculoskeletal-2026, G.2]

Initial care without the treatment package

NCCI describes circumstances where only initial cast, splint or strap care is expected and no other definitive procedure or treatment is performed. The professional-service reporting pathway can differ from treatment that includes follow-up. An E/M service still requires its own significant, separately identifiable work; the decision to perform a minor procedure alone does not establish it. [ncci-musculoskeletal-2026, G.8–9]

For a fictional urgent-care record, write exactly what assessment, immobilization and referral occurred. Do not assume that referral always means no fracture treatment was furnished, or that the first clinician always owns the complete global package. Read the treatment definition and the actual services.

If treatment is furnished but subsequent care will be provided elsewhere, return to the current surgical-care and transfer instructions from the global-surgery lesson. The reporting issue is different from a record in which the defined treatment was never performed.

Removal and replacement are different questions

For the same entity, the original application includes subsequent removal under NCCI. The entity can include the practice or group, so a different employee removing the device does not necessarily establish a different reporting party. [ncci-musculoskeletal-2026, G.1]

Original fictional follow-up: the same practice removes a cast applied earlier by that practice. The staff member is different. Do not infer separate cast-removal reporting solely from the change in staff. If another entity originally applied it, investigate the different circumstance through the full instruction.

A replacement application is not the same action as removal. Read the replacement reason, device, date and current global-period instructions before deciding its reporting. Keep removal, repair and replacement distinct in the worksheet.

Count treatments under the actual unit rule

A patient can have several fracture diagnoses but fewer reportable treatment units. NCCI restricts reporting for multiple closed fractures treated without manipulation by one cast, splint or strap, and extends that principle to the corresponding anatomical area even when such a device is not required. [ncci-musculoskeletal-2026, G.16,H.9–10]

For an original fictional exercise, several similar bones in one foot receive closed treatment without manipulation through one immobilization plan. Do not automatically assign a treatment unit to each diagnosis. Read the applicable NCCI unit instruction and exact entry.

This does not authorize deleting documented diagnoses. It means procedure units and diagnosis count answer different questions. Preserve the full injury record while applying the relevant procedure rule.

A conversion represents the completed repair

If closed treatment fails and the same encounter proceeds to open treatment of that fracture, NCCI reports the more extensive completed treatment. The attempted closed procedure does not become an additional completed repair. [ncci-musculoskeletal-2026, G.12,G.15]

Likewise, removing existing hardware can be included when necessary to perform another operation. Count the actual independently reportable service rather than each screw or each preliminary step. [ncci-musculoskeletal-2026, G.10,H.3]

Book drill

Compare three records: treatment without manipulation and planned follow-up, reduction followed by immobilization, and temporary comfort splinting with referral. Locate the current definitions before selecting any procedure. Then read the initial-cast inclusion, same-entity removal rule and multiple-fracture unit policy.

Checkpoint

Explain why a closed injury can receive open treatment, why a cast does not prove manipulation, and why several fractures need not produce the same number of procedure units. State the follow-up and treatment facts that distinguish the reporting pathways.

Check the two-column record

Keep injury classification separate from treatment technique. Preserve what was actually completed, who will provide subsequent care and which immobilization work is included. Verify units from the applicable rule rather than counting diagnosis labels.

Sources

1. CMS — Medicare NCCI 2026 Chapter IV: Musculoskeletal System. 2026. Accessed 2026-09-10.
2. AMA — Coding Update: Revisions to the Musculoskeletal System Introductory Guidelines. 2022 explanatory update; verify current licensed introductory instructions. Accessed 2026-09-10.