ED Coding and Reimbursement Alert

The materials used will help to narrow down your selection.

When a patient reports to the ED with an injury that requires a splint or strap, coders must know the difference between the two in order to assign the correct procedure code. Review these rules to make sure your code choice is secure.

Is it an initial or replacement procedure? CPT^® includes a special section on application of casts, strapping and splints arranged by body area (i.e. body and upper extremity or lower extremity). Use those codes, 29000-29799, to report any splinting and strapping services. The preamble to that section offers two scenarios for coding the application of splints and strapping:

• the service is a replacement procedure used during or after the period of follow up care (whether or not the physician provided restorative treatment [fracture care] to the patient); or
• the service is an initial service performed without restorative treatment or procedures(s) to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient .

The second scenario is most common in the ED setting, says Betty Ann Price BSN, RN, President and CEO of PRCS, Inc. in Palmetto Florida. However, don’t overlook the instructions concerning whether the ED physician provided at least partial restorative care. If restorative care is provided, report the appropriate fracture/dislocation code instead of the splint or strapping code. 

 If that is the case, remember to attach modifier 54 (Surgical care only) when the patient is being referred for follow up care.  CPT^® specifically states in this preamble that the application of an initial splint or strap may be reported with an additional E/M code if appropriately documented as separately identifiable. CPT^® is also clear that restorative treatment by another physician after the application of the initial splint or strapping may be reported with a treatment of fracture or dislocation code.

Once you decide the encounter has met splinting or strapping parameters, you’ll next select a code from the 27000-27999 series in CPT^®. But in order to finalize your selection, you’ll need to know which applications payers will consider a splint and what they’ll consider a strap, says Price.

Hold Tight to These Strapping Application Pointers

Strapping definition: Payers generally consider strapping the application of adhesive tape, one overlapping the other, to provide support and/or restriction of movement of ligament structures by exerting pressure upon the extremity or other area of the body. Strapping requires specialized skill and knowledge of the anatomical structures as well as application technique.

A specific method of strapping is the application of an Unna boot (CPT^® 29580).  An Unna boot is a paste bandage which consists of gauze that has typically been impregnated with zinc oxide, and may contain other emollients. The bandage is applied to the leg from the toe to the knee by overlapping wraps of impregnated gauze. The Unna boot bandage restricts the volume of the distal lower extremity, controls edema, and promotes venous blood return. The Unna boot is particularly useful for venous stasis ulcers or ankle sprain with severe swelling. 

Another example of strapping is buddy tape or “buddy splint” (CPT^® 29280, 29550).  This strapping application typically involves wrapping tape around both an injured digit and an adjoining digit to treat a finger sprain or toe fracture.    While it may be referred to as “buddy splint,” this procedure is appropriately coded as strapping. 

Rule of thumb: A strap is something used to bind surfaces together or to give support or compress a body part (e.g., wrapping tape around a sprained ankle).

Review Relevant Payer Rules Before Adopting Group Policy

Payers and clinical conventions support the use of strapping when the physician has stabilized a joint with non-rigid materials allowing the patient to retain some range of motion, such as tape, web rolls and possibly an elastic (e.g. ACE) bandage. But the sole use of elastic bandages as strapping may be controversial among certain payers.

Coders can approach this issue by doing a little research with payers and creating a practice policy specifying which materials are appropriate to use for strapping.

Policies regarding reimbursement for strapping and taping by health care professionals vary greatly from state to state. Review payer policies to determine which codes apply and work best for your practice.

If the payer does not accept an elastic bandage wrap as strapping, then you will likely be limited to coding the appropriate level evaluation and management (E/M) code.

Clinical coding example: A patient reports to the ED after stumbling, falling, and hyperextending his left ankle while walking his dog. During a Level 3 ED evaluation and management (E/M) service, the physician diagnoses a sprained ligament of the left ankle. The physician applies layers of web roll followed by adhesive tape to stabilize the ankle followed by application of an elastic bandage to the patient’s ankle and foot.

You should use a strapping code in this scenario. On the claim, report the following codes:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity) to evaluate the injury, rule out additional injuries and manage pain as needed. 
• Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99283 to show the E/M and strapping were separate services.
• 29540 (Strapping; ankle or foot). Modifier LT may be applied as appropriate to indicate the affected limb. 
• ICD-9 code 845.00 (Sprains and strains of ankle; unspecified site) (ICD-10 S93.402A, Sprain of unspecified ligament left ankle, initial encounter) linked to 29540 and 99283-25.
• ICD-9 code E885.9 (Fall from other slipping, tripping, or stumbling) (ICD-10 W01.0XXA, Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter) linked to 99283-25.

Look For Rigid Materials With Splint

Whereas straps are typically combinations of tape, bandages or some other flexible material, splints are made of harder stock. “Splinting is the application of a device made of rigid material including metal, plastic, fiberglass or plaster. Splints are used for stabilization, protection, and patient comfort for an injury such as a sprain, fracture, or dislocation, says Price.

Static versus Dynamic Splints

A static splint has no moving parts, protecting, immobilizing and providing stability for an acute injury. The static splint is most frequently utilized in the Emergency Department. Dynamic splints have moving parts (e.g., hinges, springs) that allow for limited movement and/or resistance during rehabilitation.

Rule of thumb: Splinting is an application of an appliance used for the fixation, union, or protection of an injured body part; it may be movable or immovable.

Remember:  According to Medicare rules, in order to report splinting or strapping codes, documentation must support that the physician or NPP directly participated in the application process, Price adds. CMS directs ED providers to bill for splints only if the splint is personally applied by the physician or NPP, when the NPP is a member of the ED physician group.

CMS Carriers referenced the fact that “incident to” rules do not apply in the hospital setting under Medicare Part B and referred to Chapter 15, Section 60-0B and Section 60.1B (B-3 2050.1) of the Medicare Benefit Policy Manual, which states that a physician may not bill for the services of a hospital employee “incident to” the physician service.

Bottom line: Provider documentation is the key to determine whether a strapping or splint application code is appropriate. When in doubt, the best coding practice is to ask the provider for clarification, says Price.