ED Coding and Reimbursement Alert

When a patient needing a splint or strap reports to the ED, coders must know the difference between the two, because their code choice will depend on it.

The catch: Payer policies really don't provide much coding guidance on splinting and strapping.

Because there are no universally accepted rules to direct you, what constitutes a splinting or strapping procedure is open to interpretation. However, we talked to some coding experts and got the lowdown on the most generally accepted coding procedures for splinting and strapping encounters.

You-ll use the 29000-29799 CPT code set to report splinting and strapping services, says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

Moore says you can report a splinting or strapping code when:

- the service is a replacement procedure (whether or not the physician provided definitive [fracture] care to the patient); or

- the service is an initial service and the physician does not provide definitive (fracture) care to the patient.

"However, if the ED physician provides at least partial restorative care, report a fracture/dislocation orthopedic code. When reporting the fracture/dislocation codes, be sure to attach modifier 54 (Surgical care only) if the patient is being referred for follow-up care," says Sherry Milligan, CPC, coder at West Physician Services in Klamath Falls, Ore.

Once you decide the encounter has met splinting/strapping parameters, you-ll next select a code from the 29000-29799 series. But in order to nail your selection down, you-ll need to know what your payers will consider a splint and what they-ll consider
a strap.

Remember: In order to report splinting or strapping codes, you must prove that the physician was directly involved in the process, not solely a nurse or other staffer.

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," Milligan says. Strapping requires specialized skill and knowledge of the anatomical structures as well as application technique, Milligan adds.

Think of it this way: "A strap is something used to bind surfaces together or to give support or compress a body part (e.g., wrapping an ACE bandage around a sprained ankle)," Moore says. (Before coding an ACE bandage wrap as a strapping procedure, read "Bandages May Not Be Aces With Payers" on page 63.)

Consider this example from Moore: A patient reports to the ED after slipping and twisting his ankle while jogging. During a level-three evaluation and management service, the physician diagnoses a sprained ankle. The physician tapes the ankle to stabilize it and applies a two-foot, 2-inch-wide ACE bandage to the patient's ankle and foot.

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

- 29540 (Strapping; ankle and/or foot) for the strapping.

- 845.00 (Sprains and strains of ankle; unspecified site) attached to 29540 to represent the sprain.

- E885.9 (Fall on same level from other slipping, tripping, or stumbling) attached to 29450 to represent the cause of the injury.

- 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) for the E/M service.

- 845.00 attached to 99283 to represent the sprain.

- E885.9 attached to 99283 to represent the cause of the injury.

Remember: 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 that the E/M and strapping were separate services.

Note: EDs cannot bill for the straps or splints they provide; the facility captures those charges. So never report supply codes when coding for a splinting or strapping procedure.

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

Think of it this way: 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," Moore says.

These splints could come ready-made "out of the box," or they may be molded by staff out of fiberglass, plaster, or some other hard substance, says Rebecca Parker, MD, FACEP, chair of ACEP's Coding and Nomenclature Advisory Committee, and president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill.

"These [materials] are more rigid and are placed to immobilize the joints above and below the fracture," Parker says.

Consider this example from CPT Assistant 2002: A 67-year-old female presents to the ED after falling off a three-step ladder. After a level-three E/M service and review of radiographs, the physician determines that the patient has a nondisplaced fracture of the distal left ulna.

Due to the swelling, the physician applies a plaster-molded splint for immobilization and protection of the fracture. The patient is then referred to an orthopedic clinic for follow-up treatment in two days.

You should code this scenario as a splinting procedure. On the claim, report the following codes:

- 29125 (Application of short arm splint [forearm to hand]; static) for the splinting.

- 813.43 (Fracture of distal end of ulna [alone]) linked to 29125 to represent the fracture.

- E881.0 (Fall from ladder) linked to 29125 to represent the cause of the injury.

- 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) for the E/M.

- 813.43 linked to 99283 to represent the sprain.

- E881.0 linked to 99283 to represent the cause of the patient's injury.

Remember: Attach modifier 25 to 99283 to show that the E/M and splinting were separate services.

Setting your own policy? If you are thinking about setting a splinting and strapping policy for your ED, Parker recommends that you first consult ACEP's "Orthopedic FAQs." To access the FAQs, go to www.acep.org/webportal/PracticeResources/issues/reimb/faqs/ROrthopedicFAQs.htm.