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Orthopedic Coding Alert

HCFA Adds New Codes for Casting Supplies

Published on Wed Aug 01, 2001

Obtaining reimbursement for cast and splint supplies has always been a challenge in orthopedics, but HCFA (now CMS; see story on page 61) recently added complexity to the issue by introducing dozens of new temporary Q codes for casting and splint supplies. Although the HCPCS codes for cast and splint supplies are guidelines for Part B Medicare patients only, many private carriers also observe these guidelines.
 
What Has Changed?
 
Until now, coders have had few HCPCS codes to choose, primarily A4565 (slings), A4570 (splint), A4580 (cast supplies [e.g., plaster]) and A4590 (special casting material [e.g., fiberglass]). The challenge was not which code to choose but how to obtain fair reimbursement when payment policies varied from state to state and the durable medical equipment regional carrier (DMERC) was involved.
  
The recent HCFA program memorandum changes all that. Transmittal AB-01-60 introduces 51 new Q codes to use in place of A4570, A4580 and A4590. The codes cover splints and plaster and fiberglass casting materials, and they are subdivided by material, patient classification (pediatric or adult) and the type of cast applied (short arm, long leg, long arm, etc.). Although the memo is titled ""New Temporary 'Q' Codes for Splints and Casts Used for Fractures and Dislocations,"" the codes are for all procedures that require casts, splints and slings.

Old Versus New Systems for Coding

With the old HCPCS codes, orthopedic coders would indicate the CPT code for the procedure performed and choose the right supply code to describe the casting materials used, either A4580 or A4590 for plaster or fiberglass.
  
For example, for a 27-year-old patient with a fracture of the lower leg, the coder would select the appropriate CPT code, e.g., 29405 (application of short leg cast [below knee to toes]) and either A4580 or A4590 for supplies. The patient's age and the type of cast had no bearing on the supply code.
  
Under the new guidelines in the program memo, a specific supply code must be selected to indicate the type of cast, the patient's age and the material used. For the same patient whose broken leg is set with a short leg cast, the coder would now use either Q4037 (cast supplies, short leg cast, adult [11 years +], plaster), Q4038 (cast supplies, short leg cast, adult [11 years +], fiberglass), Q4039 (cast supplies, short leg cast, pediatric [0-10 years], plaster) or Q4040 (cast supplies, short leg cast, pediatric [0-10 years], fiberglass).
  
If the 27-year-old patient was fitted with a fiberglass short leg cast, the orthopedist would use Q4038, linked to 29405.
  
The following subsets of codes illustrate the specificity of the new coding system:
 Q4001-Q4002 -- adult body casts
 Q4003-Q4004 -- shoulder casts
 Q4005-Q4008 -- long arm casts
 Q4009-Q4012 -- short arm casts
 Q4013-Q4016 -- gauntlet casts
 Q4017-Q4020 -- long arm splints
 Q4021-Q4024 -- short arm splints
 Q4025-Q4028 -- hip spicas
 Q4029-Q4036 -- long leg casts
 Q4037-Q4040 -- short leg casts
 Q4041-Q4044 -- long leg splints
 Q4045-Q4048 -- short leg splints
 Q4049      -- finger splints
 Q4050-Q4051 -- unlisted and miscellaneous cast and splint supplies.
 
Note: Q4050 and Q4051 still require an itemized list of the supply and amount used, etc.
 
 
These changes went into effect July 1, 2001. Although claims using the old A codes for casting supplies are technically invalid after this date, HCFA has asked that carriers observe a three-month grace period (until Sept. 30, 2001) for providers to implement the changes.
 
Orthopedic coders hope that once the specialty gets used to the new system of coding, it will help reimbursement. ""These Q codes are very specific and therefore shouldn't require the additional documentation we've needed to provide in the past,"" says Billie Jo McCrary, CPC, CCS-P, practice manager for Wellington Orthopaedic & Sports Medicine in Cincinnati. She says that prior to the new codes, the local carrier required that they attach additional information about the supply being billed, specifying the amount of the product used, etc. ""That was because the 'A' codes were too general and could be for just about any type of casting material, and there is such a variety."" Because the Q code memo also assigns reimbursement levels to each new code, reimbursement should be more straightforward rather than subject to the discretion of the local carrier.

DMERC News
 
The memo also reports the change in the HCFA policy for processing claims for splints and slings. Previously, all claims for these items were submitted to one of four DMERCs across the country, depending on where the claim originated. The DMERC then reimbursed the provider directly for the cost of the supplies. Under the new guidelines, all claims for splints and slings will go to the local Part B provider for reimbursement. Casting supplies are still billed to the local carrier.
 
The complete HCFA memorandum on this topic can be accessed at http://www.hcfa.gov/pubforms/transmit/AB0160.pdf.
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