# Documentation for 29125



## Lynda Wetter (Jun 11, 2014)

Can someone shed some light on what type of documentation an auditor would be looking for to support 29125 or any other splint code?
Thanks


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## LYDIA123 (Jun 16, 2014)

An auditor would request that the provider have some form of documentation including the closed fracture care was provided. 


A example of documentation could be " The x-ray shows the fracture is aligned adequately with no manipulation needed at this time. A cast will be applied to the "fracture site" and the patient will return.

The documentation does not use the term "closed fracture" but the service is supported by the description of the service perfomed.


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## OCD_coder (Jun 17, 2014)

Cast application does not always indicate a fracture, a splint/cast application is inclusive to fracture surgical codes, so a re-cast/splint is reportable in the global period sometimes with a modifier 58.  There are many surgical procedures where the cast is included to the primary procedure so watch bundling edits.

The documentation we auditors look for is simply a procedure note that supports a short arm splint/cast application whether it was done by the provider or ancillary staff (when incident to rules apply). 

1.  Anatomical location
2.  Laterality
3.  Type of splint, e.g. short or long
4.  Material used, e.g. pre-formed splint
4.  who applied the splint/cast and a post application splint check by the provider


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