Casting Conundrum: Correct Coding for Casts, Splints, and Strapping

by Tanai S. Nelson , CCS, CCS-P, and Christina Benjamin , MA, RHIA, CCS, CCS-P

Correctly coding casts, splints, and strapping can be confusing. Much of the confusion is related to what type of materials are classified as casts, splints, or strapping; whether the CPT application codes or the HCPCS level II codes should be assigned; and whether the work performed is included in E/M codes.

This article provides general guidance and suggested best practices for sorting out these issues.

Defining Treatment Modality

A cast is a “rigid dressing, molded to the body while pliable and hardening as it dries,” that provides firm support; it does not allow movement. ¹ A splint is any stiff device attached to a limb in order to discourage movement. There are two types of splints: static or dynamic. ² Static splints provide full immobilization, while dynamic splints allow some movement. ³

Strapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure and hold a structure in place. ⁴

Basic Rules

One of the first principles of coding casts, splints, and strapping is to understand when a separate code can be reported in relation to a restorative treatment or procedure code. Coders should ask themselves the following questions before reporting an initial casts/splints/strapping code:

• Will any restorative treatment or procedure be performed or is one expected to be performed (e.g., surgical repair, closed or open reduction of a fracture, or joint dislocation)?
• Will the same physician assume all subsequent fracture, dislocation, or injury care?

The answers will aid coders in deciding if casts/splints/strapping codes should be reported. Final code determination should be based on the specific rules in the general guidelines preceding the application of casts and strapping heading in the CPT book.

Examples of how these guidelines should be applied in facility and physician office settings are outlined below.

ED Visit

A patient is diagnosed with an ankle fracture in the emergency department. The physician applies a short leg cast and refers the patient to an orthopedist.

If the physician applies the cast, coders should report the code for the application of the cast. If the hospital staff applies the cast, the facility will report the same code. The facility should also charge for the supply, as appropriate.

Orthopedic Visit

The same patient presents to the orthopedist for definitive treatment. Closed reduction with manipulation is performed and a cast applied.

Coders should report the CPT code for closed treatment of the fracture only, because cast application is integral to any definitive fracture treatment. The physician may report supplies with the appropriate Q codes.

If the closed reduction had been performed in the emergency department, the facility would only assign codes for the treatment and the supply, if applicable, but not for the application of the cast.

If the same physician will not provide follow-up care, modifier 54 should be assigned to the CPT code, and the second physician who provides the follow-up care (involving more than just cast or splint removal or replacement) should assign the same code with modifier 55.

The patient returns to the same physician for follow-up care, and the physician replaces the cast. The physician can report the code for the application of the cast and supplies. CPT allows separate coding and charging of any follow-up care related to the condition and devices used, including application of casts, splints, or strapping if definitive treatment has already been performed.

The same patient then returns to the same physician, who removes the cast. The physician may not report the removal of cast, because the removal by the same physician or a physician in the same physician group is included in the application code. The removal of cast codes may only be assigned when a different physician in a different physician group removes the cast.

The intent of the CPT casts/splints/strapping code series is the same for both physician and outpatient hospital reporting; however, carriers and fiscal intermediaries have established different guidelines for facilities and physicians. The following discussion outlines what is considered best practice guidelines for each setting.

Physician Office Reporting

In the physician office setting, the CPT application codes are assigned along with a code for the supplies and materials. The supplies and materials can be billed separately using CPT code 99070 or HCPCS Q codes. There are two separate Q codes for the material for casts or splints that are made of any type of material. The Q code for splints includes the material for strapping.

The most conservative position by a Medicare carrier on the issue of CPT application codes is that these codes should be assigned only if the cast or splint is fabricated or custom-made and prepared with the materials specified in the Q codes. Therefore, if the cast or splint is prefabricated, only the evaluation and management code is assigned with a supply code. The reasoning is that the CPT application codes represent the work and expertise required for applying a fabricated or custom-made device.

Suggested best practice in the absence of official guidance would be to assign the application code only when the device is fabricated or custom-made. Each office should verify the guidelines with its carrier.

Hospital Reporting

In the facility, the application code is not always assigned with the supply code and therefore can be more challenging. Facilities have more choices in the supply codes for these devices, including HCPCS L codes. The question arises as to when facilities would use the application codes in conjunction with the supply codes.

In the April 2009 OPPS update, CMS instructs hospitals to report only the HCPCS supply code if the code description refers to the inclusion of fitting and adjustment. The HCPCS code for the device already includes the services identified in the CPT application codes. Coders should keep in mind that all procedures reported in the hospital outpatient setting must be done under physician supervision per the 2009 OPPS final rule, regardless of which staff member applies the device.

As an example, coding L1800 and 29515 together is inappropriate because L1800 includes fitting and adjustment, which is equivalent to application of the device. In most cases, a prefabricated device is billed with an L code, which precludes the use of the CPT application codes. Several of the codes also refer to custom-made devices such as L3670–L3673, which also include the fitting and adjustment verbiage.

There are only a few HCPCS codes that do not include application. In these cases, the appropriate CPT level 1 code is assigned to represent the application of the device. For example, S codes refer to prefabricated splint devices, but they do not mention fitting and adjustment. If a payer accepts these codes, then the application for the device may be assigned from the CPT code set.

According to the AHA Coding Clinic for HCPCS , a facility may report a CPT code for application of prepackaged splints. Further clarification states that no specific CPT codes differentiate between immobilizing devices that require little or no technical expertise and splints that are fabricated or off the shelf. Prepackaged or prefabricated splints are coded the same as fabricated or custom-made splints. CPT codes for application of casts, splints, or strapping do not specify the type of device or material used or the work required for applying a prefabricated or custom-made splint. Note that this guidance is different from some payers' interpretation of the CPT codes for physician reporting.

Miscellaneous Supplies

Per AHA Coding Clinic for HCPCS ace bandages and slings are often used with casts and splints and are not separately reportable. However, the supply may be billed separately. Without specific guidance, the best practice is to consider these supplies as part of the E/M service.

Some supplies such as splints and post-op shoes applied after surgery, used only to augment wound repair, are considered part of the operative procedure. Best practice guidance is to charge only the supply for these items. Otherwise, and in the absence of specific guidance, if the OCE edits allow billing for the application of splints with wound repair, then it is appropriate to assign these codes together.

Notes

1. Dorland’s Illustrated Medical Dictionary, 31st edition. Philadelphia, PA: W.B. Saunders, 2007.

2. American Medical Association. CPT Code Book. Chicago, IL: AMA, 2009.

3. Ingenix. Coders’ Desk Reference for Procedures. Eden Prairie, MN: Ingenix, 2009.

4. Dorland's Illustrated Medical Dictionary.

References

American Hospital Association. AHA Coding Clinic for HCPCS , first quarter (2007): 9

American Hospital Association. AHA Coding Clinic for HCPCS , second quarter (2002): 3.

American Medical Association. AMA CPT Assistant 19, no. 5 (May 2009): 8.

American Medical Association. AMA CPT Assistant 6 , no. 2. (Feb. 1996): 3–5.

Tanai S. Nelson (tanai.nelson@ahima.org) is a practice resources specialist for AHIMA, and Christina Benjamin (cmbenjamin@bellsouth.net) is an independent coding and education consultant.