ED Coding and Reimbursement Alert

Stepping up from the foot to the ankle is a great place to brush up on your coding for splints 

When do you report a short leg splint for ED patients?

There are a variety of injuries below the knee that may or may not involve the use of a short leg splint. And there are times when that splint can be coded and billed and times when it can't. Consider the following scenarios involving patients whose treatment included the application of a short leg splint.

Short Leg Splint Patient 1

44-year-old female who presents to the Emergency Department for left ankle pain after falling at home around midnight tonight. The patient states that she tripped over her scale in the bathroom and now has a moderate amount of pain in her left ankle. Her pain is exacerbated with palpation, walking, weight bearing and movement and no relieving factors. She denies numbness or tingling.

Musculoskeletal Exam: Ankle/foot: Left lateral malleolus swelling. Pain with palpation, flexion and extension, normal pulses.

Procedure
Fracture/ Dislocation Procedure
Confirmed: Patient, procedure, side, and site correct.
Indication: Fracture.
Location: Left, Ankle.
Pre-procedure exam: Circulation, motor, and sensory intact.
Procedural sedation: None.
Immobilization: Splint: Posterior, sugar-tong, Orthoglass splint and crutches.
Patient tolerated: Well.
Complications: None.
Performed by: Self.
Total time: 10 minutes.

Follow up with: Orthopedics tomorrow morning for casting. Ice Instructions: It is okay to apply ice to injured area. Ice the area 20 minutes each hour while awake. Do not put the ice directly on skin. Use a cloth bag or apply through a cloth.

Short Leg Splint Patient 2

HISTORY OF PRESENT ILLNESS

Chief Complaint: Injury to the left ankle. The injury happened just prior to arrival. The patient sustained a twisting injury and direct blow but did fall. This was not caused by a crush injury or puncture wound or an incised wound. Patient is experiencing severe pain. Patient denies injury to the head or neck. No other injury.

Extremities Exam: Left ankle: mild erythema, severe tenderness and moderate swelling and deformity consistent with an ankle fracture. Limited ROM secondary to pain. Medium sized joint effusion present. Neurovascular intact distally. No laceration, abrasion, ecchymosis, puncture wound or foreign body. No foot injury. Foot and ankle exam otherwise negative. Extremities otherwise negative. Gait: Gait not tested due to pain.

LABS, X-RAYS, AND EKG

Lt Ankle X-ray: Left ankle fracture. Dislocation of the ankle. The X-rays were independently viewed by me and interpreted contemporaneously by me.

PROGRESS AND PROCEDURES

Reduction of Dislocated Ankle: Given Morphine. The left ankle was reduced with the foot dorsiflexed and movement of the foot medially. Reassessed post-procedure: neurovascular status intact; posterior splint applied.

Splint Application: Short leg and stirrup fiberglass splint applied to left ankle. Splint applied by ED physician. Reassessed extremity following splint application. Neurovascular intact. Follow-up recommended. The ankle was reduced and splinted by the ED physician. Discussed case with on-call health care provider, Dr Ortho @ 11:20. Reviewed test results and need for additional work-up. Agreed upon treatment plan and need for patient follow-up. The patient is expected to follow up with the Dr. Ortho in 5 days as requested by Dr. Ortho.

Short Leg Splint Patient 3

HISTORY OF PRESENT ILLNESS

Chief Complaint: Injury to the right ankle. The injury happened today. The patient sustained a twisting injury at bible camp.

Patient is experiencing severe pain. No other injury.

Extremities Exam: Right ankle: moderate tenderness and swelling and small ecchymosis localized to the lateral ligaments and malleolus, anterior ankle and proximal foot. Limited ROM secondary to pain and swelling. Neurovascular intact distally. No abrasion, puncture wound, foreign body or deformity. No foot injury. Extremities otherwise negative. Neuro, Vascular and Tendons: Vascular status intact. Sensation intact. Motor intact. Tendon function intact.

X-ray interpretation: Negative for fracture.

PROGRESS AND PROCEDURES

Splint Application: Aircast Air-Stirrup Ankle Brace applied to right lower extremity. Splint applied by ED physician. Reassessed extremity following splint application. Neurovascular intact. Discharge Condition: stable.

While Each Scenario May Have Had a Great Cast, Only One is a Winner Here

After reviewing these three cases, Thomas advises that while all three of these patients had a short leg splint applied only one would be reported with 29515 (Application of short leg splint [calf to foot]).

And the 29515 goes to ... Patient 1. According to Thomas, there are a couple of things to consider when assigning 29515.

• Who applied the splint? 
• If not applied by the physician, was it checked by the physician after it was applied?
• Is this a Medicare patient?
• What type of splint was applied? 
• What is the diagnosis that warrants the application of the splint?
• What are discharge instructions?

Don't Let "Incident to" Rules Cause You A Compliance Incident

Why does it matter who applied the splint or if it is a Medicare patient? CMS policy requires the ED physician to personally place the splint, strap, or cast to accurately report a splint or fracture code for Medicare patients, Thomas says. This is based on the CMS policy for Services and Supplies Furnished Incident to a Physician's/NPP's Professional Service. Services performed by auxiliary personnel in an inpatient or outpatient hospital setting are not covered as "incident to" services, and services provided by auxiliary personnel not in the employ of the physician, even if provided on the physician's order, are not covered as incident to services.

Since Medicare does not allow incident to billing in a hospital setting, a physician cannot order or supervise a service by ancillary personnel and bill it as a professional service. The ED physician must personally perform the procedure. This would apply to procedures that are performed by nurses, techs or other ancillary staff, Thomas explains.

For non-Medicare patients, the general consensus is that the emergency physician has a little more flexibility to supervise or perform a post-placement check of the application and still code for the application of a splint. 

Off the Shelf Means Off the Table for Billing Purposes

Why does the type of splint need to be documented? CPT^® and CMS communications have made it clear that the application of an off the shelf or premade splint is not separately reportable as a physician service. Per CPT^® Assistant^® "Splint application requires creation of the splint" and from Noridian Administrative Services "The application of the prepackaged splint is a bundled service when performed on the same day as an Evaluation and Management (E&M) service or other procedure and may not be separately billed." So it is important that the type of splint applied is documented in the ED charts so the coder can determine it if was made from raw materials or an off the shelf product. 

How do the diagnosis and discharge instructions impact whether we can bill the splint application? According to CPT^® guidelines, you can only report splint application when it is performed without a code for restorative fracture care. So, if the splint is applied for a non-fracture diagnosis it may be separately reportable. If there is a fracture, the splint could be reported if the ED physician did not provide the definitive fracture treatment.

A closer look at the example patients shows that patient 1 had a Posterior sugar-tong splint made from Orthoglass that was applied by the ED physician. The diagnosis or "indication" is fracture, but the patient is being sent to the orthopedic physician the next day for casting. This indicates that the splint applied in the ED is temporary pending definitive care by ortho the next day. Therefore, it would not be appropriate for the ED physician to report the fracture care code because he is not providing definitive or restorative care. Had the ED physician performed the same care as the Orthopedist, the fracture care code would be reported and the splint would be bundled.

The treatment for patient 2 included a stirrup fiberglass splint applied to left ankle by the ED physician. But only after they had reduced the displaced fracture, therefore this would be more accurately reported with 27840 (Closed treatment of ankle dislocation; without anesthesia). Since the ED physician is only providing the surgical portion of the care and will not be performing any of the follow-up work 27840 should be reported with modifier 54 (Surgical care only) attached. Since the CPT^® code for the restorative care is being reported the splint code is not reported separately.

"It is worth mentioning that the documentation by the ED physician for this procedure and diagnosis could be better. The x-ray reading is simply 'ankle fracture' so the coder doesn't know if this is bimalleolar, trimalleolar, medial malleolus, etc. This will affect the ICD-10 code that is assigned and it could impact the CPT^® codes assigned as there are different codes for fracture treatment of the various fractures," Thomas says.

For patient 3, the splint applied in the ED is an air cast splint which is an on off the shelf product, separately reporting for the application of the splint would be contrary to CPT^® and CMS guidance, Thomas adds.