Orthopedic Coding Alert

Question: I am confused about billing for materials used for casting. Can you please clarify what can be billed and how it should be coded?

Ohio Subscriber

Answer: As with many coding issue, there is no cut-and-dry answereach practice should be familiar with the payment rules of their carriers, says Susan Callaway-Stradley, CPC, CCS-P, independent coding consultant and educator in North Augusta, S.C. Vague and conflicting guidelines cause much of the confusion. CPT has two statements that are important when coding for casting:

1. In the guidelines for the musculoskeletal section, CPT states that, the services listed below include the application and removal of the first cast or traction device only. Based on these guidelines, you may not bill for the original cast placement.

2. In the guidelines for casts and splints, CPT includes the phrase use the casting, strapping and/or supply code which leads many carriers to determine that it is an or instead of an and situation. CPT policy is that the supplies should be billed. Also according to CPT, you would report only supplies that are over and above those included with the office visit or other services rendered.

3. Medicares policy on casting and supplies is printed in its entirety here:

2079. SURGICAL DRESSINGS, AND SPLINTS, CASTS AND OTHER DEVICES USED FOR REDUCTIONS OF FRACTURES AND DISLOCATIONS

Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other healthcare professional to the extent permissible under state law. In addition, surgical dressings required after debridement of a wound are also covered, irrespective of the type of debridement, as long as the debridement was reasonable and necessary and was performed by a healthcare professional who was acting within the scope of his or her legal authority when performing this function. Surgical dressings are covered for as long as they are medically necessary.

Primary dressings are therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin. Secondary dressing materials that serve a therapeutic or protective function and that are needed to secure a primary dressing are also covered. Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings. Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings. Some items, such as transparent film, may be used as a primary or secondary dressing.

If a physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the healthcare practitioner. (See 2050.1, 2154, 2156, 2158 and 2160.) When surgical dressings are not covered incident to the services of a healthcare practitioner and are obtained by the patient from a supplier (e.g., a drugstore, physician, or other healthcare practitioner that qualifies as a supplier) on an order from a physician or other healthcare professional authorized under state law or regulation to make such an order, the surgical dressings are covered separately under Part B. Splints and casts, etc., include dental splints.

HCPCS 2000 lists A4580 (cast supplies, plaster) as having special coverage instructions and references MCM 2079. Code A4590 (special casting materials, e.g., fiberglass) is listed as being subject to carrier discretion which means you should contact your local Medicare carrier for coverage instructions. Our research found:

There are wide variations in payment of casting supplies by individual payers, whether commercial or Medicare. Some Medicare carriers pay for casting supplies and some deny these services.

Some practices routinely bill all their payers, including Medicare, for casting materials even though Medicare and many of the commercial payers do not reimburse them. The practices recommend doing the billing this way for consistency.

Anything related to cast caree.g., bandagesgiven to a patient to take home can be billed to Medicare.

Getting clarity on whether to bill for casting materialswhether you will be reimbursed and whether it is worth the timerequires a carrier-by-carrier call.