Wiki Splinting and Casting Documentation

tammymills97

Contributor
Messages
24
Location
Bourbonnais, IL
Best answers
0
Our medical group is starting an ortho practice and I am looking for examples of proper splinting and casting documentation. The provider that will be starting this group stated that he is not sure he was documenting properly in his previous practice. I want to get him set up correctly before we start bringing on additional providers. Any examples would be greatly appreciated.
 
Proper documentation of casts and splints

Splinting is usually not billed as these are usually placed for fracture care. Your physician should state specifically that it was placed and anatomically where. Some insurances will bundle with the office visit, just keep track of which insurance covers and who does not.

For casting documentation the physician really needs to document if the cast was made from casting materials, or if it was DME. For example, a "spica" splint can be either placed by the doc using casting materials, or a DME product. This is a very important distinction. You don't want your coder billing casting and supplies if the spica splint was taken from the closet. Your patient will call and get upset thinking you don't know what your doing. Specificity is key here. And it seems dumb, but patients will judge you if you bill wrong.

If the doc places a cast, make sure he states the type (long arm, short arm) and materials used. If the doc places a DME product, make sure that is specifically documented.

When I first started this drove me crazy since the docs just stated that they placed a cast without any other information. You don't want them doing that.
 
Last edited:
Top