ED Coding and Reimbursement Alert

To ensure correct coding for the application of a splint by the emergency department (ED) physician, coders must check with their local carriers to determine what documentation is needed to bill for a splint if a physician orders it and then a nurse or technician applies the splint.

Many coders believe that splinting codes 29105 (application of long arm splint [shoulder to hand]), 29125 (application of short arm splint [forearm to hand]; static), 28126 ( dynamic), 29130 (application of finger splint; static), 29131 ( dynamic), 29505 (application of long leg splint [thigh to ankle or toes]) and 29515 (application of short leg splint [calf to foot]) cannot be used if the physician does not apply the splint. But coding experts disagree on whether a physician must physically apply a splint in the ED to bill for it.

If the physician must apply the splint to be permitted to code for it, it could be a problem for some. That rarely ever happens in our facility, explains Rebecca Bennett, RHIT, outpatient coder at Heartland Regional Medical Center in St. Joseph, Mo.

Jan Rassier, RN, the ED reimbursement coordinator for Edward Hospital in Naperville, Ill., codes for 18 physicians employed by the hospital. Im hearing two separate things. The experts are disagreeing. Some experts wont code for it [splint application], but others will, she says.

Rassiers approach accounts for Medicares stance on procedures not performed by the physician. I dont code Medicare patients for a splint application, Rassier explains. Medicare gets very prickly about paying for procedures that are not specifically done by the physician. I do code other payers, however. Its a service that I feel I can defend because there arent any hard and fast rules specifically that say the doctor must perform the procedure.

Addressing the Confusion

That lack of hard and fast rules is causing the confusion. But some of that confusion can be cleared up by Kenneth DeHart, MD, president and CEO of Carolina Health Specialists physician group in Myrtle Beach, S.C. DeHart is a former chair of the American College of Emergency Physicians (ACEP) coding and nomenclature advisory committee and a past member of the American Medical Association (AMA) CPT-4 editorial panel.

I was one of those responsible for the authorship of the amended splinting language, DeHart explains. When it was discussed behind closed doors at the CPT editorial panel, the issue was specifically discussed whether the physician needed to put the splint on or not. It was the consensus of the panel that it was not necessary for the emergency physician to actually put the splint on, but to document the effectiveness of it.

According to DeHart, the panel considered the following example at that meeting: Casting technicians typically replace casts; orthopedic surgeons are not required to do so as part of the global fracture care. DeHart concurs that the CPT editorial panel could have provided more direction. Because of this lack of direction, DeHart says coders should check with local carriers when billing for a splint applied by a nurse or technician.

Its conceivable, in the absence of that direction, that local carriers could develop policy that differs from our intent, DeHart explains. Having been there, in the discussion, I feel very comfortable in my position that it is not necessary for the physician to apply the splint, but it is crucial that the physician document the effectiveness of it.

I have no problem saying that I was one of the authors of the amending language and we specifically discussed it and it was our conclusion that the emergency physicians need not put the splint on, DeHart adds. I think its very defensible. On the other hand, it is certainly not beyond the possibility that [local carriers] could be writing their own interpretations.

Note: Keep in mind that the application of splints, casts and strapping is separately reportable only when the ED physician has not reported an orthopedic code for his or her service involving a fracture or dislocation.

Document the Effectiveness of the Splint

If your local carrier allows splints applied by nurses to be billed, it is important to document in the chart that the physician ordered the splint and then checked it before the patient left the hospital.

I think one of the things that one would want to address, not just for compliance or reimbursement issues but also for quality-of-care issues, would be the effectiveness of the immobilization and any evidence of neurovascular compromise, DeHart explains.

Rassier also is strict about the documentation provided by the physicians with whom she works with. They must state specifically [in their documentation] that the splint is in proper position. If they dont say that, then I dont code it.

Be Cautious

Because the CPT language doesnt completely clear up the misunderstanding, many coders say that they wont code for a splint applied in the ED unless the physician does the splinting.

For governmental payers, I would suggest a more conservative approach unless advised otherwise, explains Caral Edelberg, CPC, CCS-P, president of Medical Resource Management Inc., an emergency department coding consulting firm in Jacksonville, Fla. Because Medicare has specifically removed the application of incident-to guidelines from the ED, it follows that the physician must be personally involved in the placement or review of placement. For nongovernmental payers, a more liberal approach might be appropriate in the absence of direct guidelines.

Most of the confusion stems from the wording in CPT. The definitions for the splinting codes in CPT specifically state application. For example, 29105 includes application in its descriptor, as does 29505.

If you think of an analogy like thrombolytic therapy, the physician doesnt push the thrombolytic. He or she is really supervising the thrombolytic therapy, explains Bart Hershfield, MD, FACEP, reimbursement committee chairman of the West Virginia ACEP. Clearly in this case, it is OK for the physician to supervise and document it. The question is, can you make the same analogy to splinting, especially when CPT says the application? Is it legitimate to supervise the application, particularly when there is no incident to in the ED?

Hershfield says the wording in CPT is enough reason for caution. I feel more comfortable if the physician actually does the splinting, he says. I know that its been said that as long as they order it and clearly supervise it by going back and confirming proper position, confirming that there is good neurovascular status, that its OK to go ahead and bill for that. To me, its just a level of personal comfort.

Another Level of Confusion

Part of the confusion surrounding this issue for some coders is determining what to bill for the hospital and what to bill for the physician. The confusion about billing comes from a lack of understanding about the difference between hospital billing and physician billing.

According to Linda Jackson, CCS-CPC, Medicare consultant at the Iowa Veterans Home in Marshall Town, Iowa, the hospital assigns a code for the splint application because it must report all procedures performed and assign CPT codes to those procedures. This is done on the universal billing form and is a way to report the type of services rendered on the facility side.

A three-digit revenue code is also assigned to indicate where and what type of service is performed. Jackson says the physician must help or supervise the splint application because in the ED, the staff members doing this are employed by the hospital. If the doctors employee were applying the splint it would be different.

On the facility (the APC) side, the answer is clear, Hershfield says. It can absolutely be billed (if the nurse or tech does the splinting). But just on the professional billing side, its not that simple. Its a lot cleaner if the provider doing the billing does the application. Then it cant be argued.