Primary Care Coding Alert

There are no bones about it: Coding for casts and strapping instead of fracture care can save your practice money and decrease denials.

"You can't bill the casting and strapping codes with the fracture care codes because casting and strapping is included in the fracture care codes," says Susan Welsh, CPC, PMCI, a coding educator and former billing coordinator for the department of orthopedics at Vanderbilt University in Nashville, Tenn. "Many coders get this confused." You can bill the casting and strapping codes only in specific situations, and you need to know when and how.

The most common use of the casts and strapping codes is for the removal and replacement of the cast, either to check the healing progress of the fracture or because the cast has become ineffective, Welsh says.

For example, an elderly patient with osteoporosis presents to the FP 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. While 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]).

"It is important to show medical necessity for the cast replacement, otherwise Medicare and most commercial carriers won't pay for it," Welsh says. In the example above, the physician would have to document thoroughly that the fracture needed to be checked because the cast was not providing full protection due to loss of muscle mass.

If the cast is removed and replaced because it smells or looks dirty, payers will not reimburse the visit, Welsh says. "A lot of times a child with a cast has been playing on the playground and got dirt on the cast, and it looks bad and smells bad," she says. "The physician can replace the cast, but the visit won't get paid for because it wasn't medically necessary."

Sometimes, however, the patient has soiled the cast so much that it is medically necessary because he or she is in danger of getting an infection. In such a case, you have to document carefully that the cast could cause skin ulcers or staphylococcus.

Replacing a damaged cast is also considered medically necessary, says Tom Felger, MD, a family physician at St. Joseph's Regional Medical Center in South Bend, Ind. "We have 12-year-old boys who get in a fight or smack around the cast so much that it's not effective any more," he says. "I replace the cast and use the casting code in those cases."

When another physician is involved in the patient's treatment, your practice can bill for specific services. CPT indicates that you can bill for the splinting when the FP stabilizes the fracture before it is definitively treated by another physician, Welsh says.

A patient may come in with a broken arm, for example, and the FP decides the fracture needs to be addressed operatively for optimum healing. The physician arranges for the patient to see an orthopedic surgeon. To minimize the possibility of further damage to the fracture, the FP bandages the arm loosely in cotton gauze and puts a splint on it to stabilize it.

In this situation, bill the appropriate splinting code (29105-29126) as well as an E/M office visit code (99201-99215). Consider using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the E/M, Welsh says. "By using modifier -25, you would avoid the possibility of a misunderstanding and improve your chances of a paid claim the first time."

It is important to note that you can only charge for the splint if your practice is not going to treat the fracture. If the FP stabilizes the fracture with a splint so he or she can treat the fracture later, you can only bill the appropriate fracture care codes. The splinting is included in the fracture care code.

If a patient was treated for the fracture by a different physician, but comes to your FP to have the cast removed, you can bill for the cast removal (29700-29715). Remember that those codes are only applicable if you did not bill for the fracture care codes because the removal is included in those codes.

Using the correct combination of diagnosis codes will help ensure reimbursement for casting services. When the FP replaces the cast because it was wet or contaminated, use V54.89 (Other orthopedic aftercare). Welsh suggests filing this code as a paper claim and including supporting documentation so the insurance company can understand why the cast had to be removed.

If the FP has to remove the cast to check on the healing of the fracture with an x-ray, you should use V54.89 and the diagnosis code used for the original fracture.

CMS added several new ICD-9 codes for orthopedic aftercare that coders should be aware of: V54.10-V54.19 (Aftercare for healing traumatic fracture & ), V54.20-V54.29 (Aftercare for healing pathologic fracture & ), V54.81 (Aftercare following joint replacement) and V54.89 (Other orthopedic aftercare). These codes will be effective Oct. 1, 2002.

Many coders make the mistake of reporting the splint or cast codes when they should be reporting the non-manipulative fracture care codes.

For example, say a patient has a fractured tibia. The bone needs to be stabilized with a cast but not manipulated. In this situation, do not use a casting code. Just because the doctor is not manipulating the fracture does not mean you can't charge the fracture care codes, Welsh says. In the above scenario you would report 27750 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation).

Another common mistake is coding for the splint when the physician is securing it for later treatment. "Sometimes, the fractured appendage is swelling and the doctor needs to wait before applying the cast," Felger says. If that same FP is treating the fracture later, you cannot bill the splinting code.