Internal Medicine Coding Alert

Tip: Remember you can always report supplies, if you meet one simple test.

Football season is in full swing -- which means the likelihood of broken bones increases. Be sure you're ready to conquer cast and splint claims by keeping these three key factors in mind.

Know These Two Cast Coding Times

Many patients keep the same cast throughout treatment, but that's not always the case. If a patient needs a replacement cast because of decreased swelling, loosening of the cast, or a broken cast, don't forget that you might be able to code the application.

Initial cast application is part of the fracture care global period, but there are two instances when you might be able to report additional casts:

Situation 1: Any replacement cast the internist applies during the global period is separately codeable. Some payers require modifier 58 (Staged or related procedure by the same physician during the post-operative period) to indicate that the cast is part of the same treatment plan, but that guideline can vary. "Medicare requires the modifier," says Ruby O'Brochta Woodward, BSN, CPC, CCS-P, ACS-OR, compliance and research specialist with Twin Cities Orthopedics in St. Louis Park, Minn. "I have successfully billed this to the private health plans without the modifier without a problem."

Example: A patient under an internist's care needs a replacement cast once the swelling in her arm goes down. You can report the replacement with the appropriate cast code (such as 29075, Application, cast; elbow to finger [short arm]), plus modifier 58.

Situation 2: Payers don't consider a temporary cast to be part of the preoperative care, so you can code for the application. Report the appropriate choice from cast codes 29000-29590 (the range of cast, splint, and strapping application codes based on the type of cast, splint, or strapping and body part).

The physician's documentation should include the application procedure, the type of cast/splint/strapping applied, the type of material used, and the reason for application.

For example, a thorough procedure note would be: "Due to the amount of swelling present I would prefer that we delay operative intervention. A well padded short leg fiberglass cast was applied to stabilize the fracture. She will follow up in 5 days for cast change, x-ray and reevaluation. Sooner if the cast becomes loose or uncomfortable." You could also report an appropriate E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to distinguish the evaluation from the cast application. You should have separate documentation supporting the E/M code reported.

Example: Depending on other details with the procedure documentation above, you might report 29425 (Application of short leg cast [below knee to toes]; walking or ambulatory type) for the initial, temporary cast. Include an E/M code (such as 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) and modifier 25 to complete that part of your claim.

Clarify the "First Cast" Rule

When your internist provides fracture management, the fracture care global period includes the first cast he or she applies for the patient. Remember, your internist doesn't always apply the patient's first cast, however.

Example: A patient is injured while on vacation and a cast or splint is applied as an initial service to stabilize the injury. The patient subsequently sees your physician, who provides actual restorative treatment for the fracture, including application of a new cast. In this example, the cast applied by your physician is included in the fracture care he or she provided and is not separately reportable, even though it technically wasn't the patient's first cast.

"The cast is billable if you are not coding fracture care," says William J. Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C. "If you're coding fracture care, the first cast is bundled in the code."

"Remember that the initial cast application is included in all the surgical procedures, not just for fractures," O'Brochta-Woodward adds. "For example, cast application at the same time as performing a joint or tendon/ligament injection is bundled into the 'surgical' procedure."

Code for Supplies Every Time

Although cast application coding can vary, you have one simple rule to remember for cast and splint supplies: they are always separately billable, assuming your internist incurred the expense for supplies.

Look to HCPCS for all your cast supply codes. Make your selection based on the patient's age, type of cast/splint, and the type of cast material.

A codes: Some workers' compensation groups prefer A codes such as A4580 (Cast supplies [e.g., plaster]) or A4590 (Special casting material [e.g., fiberglass]). Most payers do not recognize this group of codes, however, so O'Brochta-Woodward recommends verifying their use before choosing an A code for casts.

L codes: All L codes pertain to orthotic and prosthetic procedures and devices, including scoliosis equipment, orthopedic shoes, and prosthetic implants. Only turn to L codes (such as L2106, Ankle foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom-fabricated) when you're coding supplies for long-term support of a diseased or injured extremity, not your typical fracture care.

Q codes: Your best choices lie with codes Q4001-Q4048 and Q4050 that cover the gamut of cast supplies and application types. Each Q code fee includes the cast material, padding, and stockinette.

"Don't forget about waterproof cast padding such as Procel/ Gortex," O'Brochta-Woodward says. "Some health plans allow separate reimbursement for this material."

Here's how: When reporting Q codes for your cast supplies, include Q4050 (Cast supplies, for unlisted types and material of casts). Include a note in Box 19 of the supply and type of cast applied (such as, "waterproof cast padding for short leg cast").

Finally, in the absence of any better code with which to report your casting supplies, you may use 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies or materials provided]).