ED Coding and Reimbursement Alert

Question: A 60 year-old presents to the ED and is found to have a fracture of the distal ulna after a fall. The emergency physician orders x-rays, and after interpreting the films, makes the treatment decision to have the forearm casted without reduction. The actual cast is applied by an orthopedic tech without physician involvement. An EM level 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity…) was reported, but can we also bill for the cast application?

Ohio Subscriber

Answer: Since the ED physician did not personally apply the cast, nor is there documentation that he “supervised” the cast application, it is not appropriate to assign the CPT^® code for casting. Medicare rules would not allow reporting the casting services performed by someone else because the “incident to” policy does not apply in in the ED setting.

If a physician does personally apply and adequately documents the application of a splint or strap, then a splint/strap application procedure code may be reported. Local payer rules may place limits on coding for direct supervision only. You are advised to confirm the acceptability of coding and billing for direct supervision of splint/strap application with these payers.