ED Coding and Reimbursement Alert

Question: A patient presented in the ED after a fall from a ladder. During the exam, the physician performed x-rays of the forearm and discovered that the patient had a nondisplaced fracture of the distal radius. The nurse applied an orthopedic glass splint and told the patient to follow up with an orthopedist at a later date. The ED physician thinks this is restorative care, but I disagree because he did not apply the splint. Who is correct?


Georgia Subscriber

Answer: The nurse applying a splint is not likely to meet the definition of restorative care, which usually includes physician-provided reduction or manipulation of the fracture. In most emergency department communities, the physician will ultimately treat a distal radius fracture with a more permanent cast. And according to Medicare, the physician would have to directly perform the application in order for you to bill for the treatment.

Although important arguments regarding restorative care may be involved in this case, the more crucial issue here is the "incident-to" provision - which doesn't apply in the emergency department. Under this provision, Medicare allows you to bill for nonphysician services under the supervising physician's ID if the services are incident-to the physician's plan of care.

Private payers may approach this situation differently from Medicare, so before making this kind of policy decision, ask the payer about its guidelines.