Orthopedic Coding Alert

It's official: You should report either casting or fracture care, but you usually can't bill both. Version 9.2 of the National Correct Coding Initiative (NCCI), which took effect July 1, bundles scores of casting and strapping codes (29000-29590) into most fracture care codes.

The NCCI cast a wide net to bundle casting and strapping into the fracture care codes, affecting hundreds of codes in CPT's Musculoskeletal System section. For example, the edit now bars coders from reporting the upper-extremity casting codes 29000-29065 with the shoulder fracture/dislocation codes (23500-23680). Shoulder splinting (29105) and strapping (29240) are also bundled into the shoulder fracture care codes.

"Most insurance companies already bundle the initial casting code into the initial fracture treatment charge," says Betty Dively, billing supervisor at Sarasota Orthopedic Associates. She says that most fracture care claims typically include the following services:
    an exam (99201-99205 for new patients)
    an x-ray (70000 series) to diagnose the fracture
    fracture care (such as 25505, Closed treatment of radial shaft fracture; with manipulation)
    cast supplies (such as A4580, Cast supplies [e.g., plaster]).
  Dively does not include the actual casting in her initial fracture care claim. A note in CPT's Application of Casts and Strapping section states, "A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes."
  Report Casting Codes Sparingly

Orthopedists most commonly report the casting and strapping codes when they remove and replace a cast, either to check the fracture's healing progress or because the cast was damaged.

For example, an elderly patient with osteoporosis presents to the orthopedist for a follow-up visit after fracture treatment for a broken wrist. The cast is loose because the patient has lost muscle mass, so the physician removes the cast, takes an x-ray and puts a new cast on the patient.

Although you cannot bill for an E/M service if the visit occurs within the 90-day global period, you can code this visit with 29085 (Application, cast; hand and lower forearm [gauntlet]) along with the appropriate x-ray code.

It is important to show medical necessity for the cast replacement otherwise Medicare and many commercial carriers won't pay for it. You should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 29085 [...]