Pediatric Coding Alert

Reviewed on April 23, 2015; no changes to content

Coping with fractured fingers is not unusual in pediatrics. So determining the proper way to code is essential. Caroline Pelton, billing and insurance manager for Berkeley Springs Medical Associates, a three-family practitioner, one-pediatrician practice in Berkeley Springs, WV, asks how to code for wrapping a fractured finger with a splint when the finger was x-rayed in another facility. Should we use total fracture care? she writes.

When a pediatrician sees a patient for a fracture, if the pediatrician ends up providing the full care for that fracturemeaning the patient is not referred to an orthopedistthen the pediatrician can and should bill using the global fracture codes, says Tom Kent, CMM, seminar leader for McVey Associates. In pediatrics, this most commonly happens with fingers, toes, and clavicles, says Kent. (See box at the bottom of this page for the codes.)

The fracture codes include casting or splinting and care for 90 days, he says. The codes cover the whole visit, so there is no E/M code, unless some other illness was addressed.

Problems with Reimbursement
for Splint and Application

There is a CPT code for a finger splint. It is 29130 for application of a static finger splint, and 29131 for application of a dynamic finger splint. However, Dean Leanch, reimbursement analyst with Practice Solutions, a Durham, NC-based company which bills for many pediatric practices, doesnt recommend using these codes. Its better to use the office-visit codes, he says. You probably wont get paid for the splint supply if you use the splint codes. As for getting paid for the office visit and the splint CPT 99213 and 29130 or 29131he says its likely you will not get paid for both. And, in the introduction to the casts and strapping section, CPT makes it clear that an office visit is not reportable if a splint application is billed. Additional evaluation and management services are reportable only if significant identifiable further services are provided at the time of the cast application or strapping. In other words, only if you check the patient for other problems as well as the fractured finger, could you bill for both the office visit and the splint application.

Here is a scenario in which you could bill for both. You see a child who has been injured during a basketball game. After an examination, you send the child for an x-ray of a possible broken finger, but you are also concerned about the ankle, and you ask for that x-ray as well. You also must consider other possible injuries in your medical decision-making. This would justify the use of the modifier -25 on the office visit, as well as the finger splint application.

Tip: Billing both the office visit with a modifier -25 and the splint application would net you about double what you would get for the office visit or finger splint alone, so if it is justified by a separate service, it is certainly worth filing.

The splinting/cast application codes are to be used when the pediatrician applies a splint to stabilize the fracture until the orthopedist can see the patient and take over care, says Kent.

In addition to billing for the fracture care or office visit, you should bill for the splint itself using the appropriate HCPCS supply code, says Leanch. We submit the HCPCS code (A4570, splint), but some insurers need more, he notes. Its a good idea to attach a description of what the splint is. You may need to submit a copy of the invoice as well. If your experience with a certain carrier is that they want invoices, do that when you file the claim initially; that will save you time later (its always easier to copy an invoice and attach it to a claim than it is to go through an entire appeal, especially for something as small as a finger splint).

Some insurers prefer you to use the CPT code for unlisted supplies (99070). This code is for 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).