Orthopedic Coding Alert

Casts, splints and straps are immobilization devices applied to protect injured bones and soft tissue and to reduce pain, spasm, and swelling following a surgery. Application of these devices is often part of a global surgery. In that case, casting is part of the global charge and cannot be billed separately.

There are many variations on casting, however. Being alert to them means claiming all the reimbursement to which a provider is entitled.

Correct Coding for Splinting

Physicians often forget to bill for the splint when they apply one to a patients sprained finger during an office visit.

The strapping codes are rarely used in cases such as a finger sprain, says Dari Bonner, CPC, CPC-H, CCS-P, the president of Xact Coding & Reimbursement and a corporate compliance coding/reimbursement specialist for a large health system in Florida.

Bonner says, Physicians usually will bill the evaluation and management (E/M), CPT 99201 - 99220 . But they apply a splint and rarely bill for it because it is often
not reimbursed.

But coding for the splint is still a good idea. Bonner says the appropriate way to code the application of a finger splint to a sprain is to use 29130 (application finger splint, static) or 29131 (application finger splint, dynamic), where static and dynamic refer to whether the appendage can be moved while in the splint.

Coders are less likely to overlook the opportunity to claim splints for arms and legs even though the first cluster of codes in the 29000 series is for splint applications.

Note: Casting and strapping codes are in the 29000-29590 range.

Splint applications are listed for long arm (29105, application of long arm splint [shoulder to hand]) and short arm (29125, application of short arm splint [forearm to hand]; static) and (29126, application of short arm splint [forearm to hand]; dynamic), says Bonner. Long leg and short leg splint applications are subdivided on the same principle.

Bonner cautions that the 29000 series codes are only to be used when the cast application stands alone as a procedure. She says to use the series codes for the initial application when no treatment other than the application is provided.

In other words, says Bonner, no manipulation of a fracture or other surgical treatment [was initially required]. When other procedures [such as surgery] are performed, the initial application of casting, strapping or splinting is inclusive of the procedure performed and may not be billed with the initial treatment.

An example of a global CPT for surgery and casting is 27532 (closed treatment of tibial fracture, proximal [plateau]; with or without manipulation, with skeletal traction).

Replacements CountMost of the Time

There is another instance when billing for a cast is the correct course (and the 29000 series codes apply). Bonner explains coders should look to the series during the postoperative reapplication of a cast (or splint or strapping) when the replacement is due to wear and tear on the material.

The key is that if a cast change is made during the global period, a modifier, most likely -79 (unrelated procedure or service by the same physician during the postoperative period) must be used and a diagnosis code should support the need for a new cast. For example, 707.0 (decubitus ulcer; plaster ulcer) details a condition that requires a new cast application.

A cast replacement during the first 14 days of the life of the cast can be trickier. Many carriers expect the provider to replace the problem cast (e.g., ill-fitting, causing swelling) in that period without additional reimbursement.

A provider can charge for supplies during the 14-day period, however.

If an orthopedic practice provides follow-up care for a fracture that was treated in an ED, who charges for the global? It depends on how long it takes the patient to get from the ED to the orthopedic practice, who applies the cast, and the extent of the follow-up.

Note: See page 69 of the September 1999 Orthopedic Coding Alert, How to Properly Code for Post-emergency Fracture Care for a review.

If cast application is not part of a global surgery code, it can usually be billed.

Cast changes necessitated by a treatment regimen can be billed as performed using a code from the cast series and appropriate supplies from the HCPCS codes. (A4580, cast supplies, [e.g., plaster]; A4590, special casting material [e.g., fiberglass]). Consider a diabetic patient who requires several cast changes for tarsal and metatarsal protectionevery four to six weeks over 12 months, for example. Each change can be billed.

The only exception would be the initial casting. If
done under a fracture care code, it would be included in that global.

Dont Forget Supplies

Remember to bill for supplies. HCPCS codes A4580 and A4590 are the major categories to review. Claims for them are submitted to the local carrier.

Other supplies, such as those in categories A4454 (tape, all types, all sizes), A4455 (adhesive remover or solvent [for tape, cement or other adhesive] per ounce), A4460 (elastic bandage, per roll [e.g., compression bandage] and A4462 (abdominal dressing holder/binder, each), are considered incident to physicians services and can generally not be billed.

An exception: They can be billed when they are given to the patient as a take home supply. But for Medicare patients, the claims for these supplies cannot be sent to the local carrier.

Claims for A4454, A4455, A4460 and A4462 must be sent to the Durable Medical Equipment Regional Carrier (DMERC). There are four DMERCs in the United States and the claim for a Medicare patient must be sent to the one that covers the patients region.

Editors note: Reimbursement for removal of a cast is built into the application. Do not bill for it.