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Official Description

Closed treatment of scapular fracture; without manipulation

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Closed treatment of a scapular fracture without manipulation involves the non-invasive management of a fracture located in the scapula, which is the bone that connects the upper arm to the trunk of the body. This procedure is specifically indicated for nondisplaced fractures, meaning that the bone fragments remain in their normal position and alignment. During this treatment, the physician will perform a thorough evaluation of the fracture, which includes obtaining separate radiographs (X-rays) to confirm the presence of the fracture. A critical component of the assessment is the neurovascular examination, which checks the integrity of the nerves and blood vessels surrounding the injury site to ensure there is no compromise to these structures. Since no manipulation of the fracture fragments is necessary in this case, the treatment focuses on immobilizing the shoulder to promote healing. This is typically achieved by placing the affected arm in a sling, which helps to stabilize the shoulder joint and reduce movement, allowing the fracture to heal properly over time.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Closed treatment of a scapular fracture without manipulation is indicated for the following conditions:

  • Nondisplaced scapular fracture - This procedure is performed when the fracture does not result in the misalignment of the bone fragments, allowing for treatment without the need for manipulation.
  • Assessment of neurovascular integrity - A neurovascular exam is conducted to ensure that the nerves and blood vessels around the fracture site are intact and functioning properly.

2. Procedure

The procedure for closed treatment of a scapular fracture without manipulation involves several key steps:

  • Step 1: Radiographic Evaluation - The physician begins by obtaining separate radiographs to confirm the presence of the scapular fracture. This imaging is crucial for diagnosing the fracture and determining the appropriate course of treatment.
  • Step 2: Neurovascular Examination - Following the radiographic evaluation, a thorough neurovascular examination is performed. This step is essential to assess the condition of the nerves and blood vessels in the area surrounding the fracture, ensuring that there is no damage or compromise to these structures.
  • Step 3: Immobilization - Once the fracture is confirmed and the neurovascular status is deemed satisfactory, the next step is to immobilize the shoulder. This is typically achieved by placing the affected arm in a sling, which helps to stabilize the shoulder joint and restrict movement, facilitating the healing process.

3. Post-Procedure

After the closed treatment of the scapular fracture without manipulation, the patient is advised to keep the arm in the sling for a specified period to ensure proper immobilization and healing. Follow-up appointments may be scheduled to monitor the healing process through additional radiographs. Patients are typically instructed on pain management strategies and may be advised to limit certain activities to prevent stress on the healing bone. It is important for the patient to report any signs of complications, such as increased pain, swelling, or changes in sensation, to their healthcare provider promptly.

Short Descr CLTX SCAPULAR FX W/O MNPJ
Medium Descr CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION
Long Descr Closed treatment of scapular fracture; without manipulation
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6B - Minor procedures - musculoskeletal
MUE 1
CCS Clinical Classification 148 - Other fracture and dislocation procedure
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
55 Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AG Primary physician
AM Physician, team member service
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
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2023-01-01 Note Short description changed.
Pre-1990 Added Code added.
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