Primary Care Coding Alert

If you're wondering about reporting a fracture treatment and cast code for the same anatomic site on the same day, the latest edition of the National Correct Coding Initiative (NCCI) confirms that you shouldn't.

NCCI, version 9.2, effective Sept. 1, corresponds to CPT's guidelines, says Marie Felger, CPC, a family practice coding consultant and American Academy of Professional Coders certified coding instructor with Joy Newby & Associates LLC in Indianapolis. "The guidelines at the beginning of the musculoskeletal section and the application of casts and strapping subsection both clearly state that the treatment of fracture and/or dislocation codes (21300-28675) include the first cast, splint or strap application," she says.

Now NCCI is making the edits reflect this bundle, says Beth Glenn, CPC, CMA, certified coder for Jefferson Family Physicians in Jefferson City, Tenn. "The NCCI edits indicate that the application of casts and strapping codes are a component of the related comprehensive fracture code," Glenn says. Therefore, if you charge a fracture care code, you should not also bill a code for initial application of casts and strapping (29000-29590) associated with that fracture care.

Fortunately, because NCCI's bundle reinforces correct coding procedures, the new edit should not affect your practice's bottom line. The reason that both CPT and now NCCI disallow reporting a fracture care code with a related cast code is two-fold. First, the relative value units for fracture care and dislocation codes include the costs associated with the initial restorative treatment and all of the subsequent care for that condition during the global period, Felger says. Second, per CPT, the fracture service includes the initial cast, splint or strap. "Therefore, fracture care/dislocation codes and application of casts and strapping codes are mutually exclusive and not separately reportable," she says.

Fracture Bundle Example: A patient comes in with lower leg pain after falling off his bike during trail riding. He is unable to bear any weight on his leg. The family physician (FP) sends the patient for an in-office x-ray (73600, Radiologic examination, ankle; two views), which he interprets as showing a tibial shaft fracture (823.20, Fracture of tibia and fibula; shaft, closed; tibia alone). The physician treats the fracture (27750, Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) and places a cylinder cast on the patient's leg (29365, Application of cylinder cast [thigh to ankle]). Because the fracture code (27750) includes applying the initial cast (29365), you should report the fracture treatment (27750), not the cast code (29365), according to CPT as well as NCCI.

Alternatively, suppose the FP does not treat the fracture and instead places a cast or strap to stabilize the injury until an orthopedist can provide treatment. In this case, you should use the casting code (29365) and the appropriate E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ).

Although CPT already states this directive, not all FP coders adhere to these guidelines. In fact, some practices incorrectly report a cast application code each time the physician applies one, Glenn says. Not only is this incorrect coding, but payers who follow NCCI edits will now automatically reject claims containing a treatment and casting code unless the FP treats multiple injuries.

The only time that you should separately report a fracture care code and a casting code for the same patient on the same claim is if the FP treats one fracture and casts/splints or straps another injury. NCCI lists the fracture care and application codes with an indicator of 1, which means that certain modifiers, such as modifier -59 (Distinct procedural service), may override the edits in certain cases, Glenn says. For instance, if an FP treats a fracture and applies a cast to a different anatomic site, you should report both codes with modifier -59 appended to the cast code, if NCCI bundles the code set.

NCCI does not bundle all fracture care codes and casting codes. Instead, the edits include related code sets. For instance, NCCI bundles related cast and splints (29000-29105) into the shoulder dislocation treatment code (23650). Therefore, if an FP treats an unrelated fracture and cast, modifier -59 applies.

Separately Reportable Dislocation and Splint Example: A male patient presents after a motor-vehicle accident with a dislocated left shoulder (831.00, Dislocation of shoulder; closed dislocation; shoulder, unspecified) and a fractured right elbow (812.41, Fracture of humerus; lower end, closed; supracondylar fracture of humerus). The FP uses traction and relocates the shoulder (23650, Closed treatment of shoulder dislocation, with manipulation; without anesthesia). He then places a long arm splint on the other arm to stabilize the injury (29105, Application of long arm splint [shoulder to hand]) for an orthopedist to treat later.

In this case, because the FP treats different injuries, you should report both the dislocation treatment (23650) and the splint application (29105). Therefore, you will have to append modifier -59 to the splint code (29105-59) to indicate a different injury.

Lesson Learned: If you fail to follow CPT's guidelines for fracture care and application of casts and strapping, Medicare and commercial payers that follow NCCI will automatically reject claims containing a treatment and casting code.