Orthopedic Coding Alert

Note: Part two of a three-part series reviews the essentials of billing for selected supplies and orthotics for the extremities.

Correct use of the Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) codes will supplement CPT codes for reporting supplies and services. CPT codes are referred to as Level I codes, and HCPCS as Level II codes. (Level III codes are also HCPCS codes, but refer to codes used by local Medicare carriers.)

CPT code 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included in the office visit or other services rendered [list drugs, trays, supplies or materials provided]) indicates supplies that can be billed separately from an evaluation and management (E/M) outpatient service. But to be successful in garnering reimbursement, you must use HCPCS Level II codes instead of (or in addition to) the CPT code.

Things You Must Know About HCPCS Codes

Medicare, Medicaid and most commercial carriers require orthopedists to use HCPCS codes for supplies and orthotics. Carrier discretion on reimbursement for HCPCS coded items is wide. Moreover, the same insurer often offers different plans to subscribers. In other words, it cannot be assumed that all Blue Cross/Blue Shield plans pay for a fiberglass cast; some do, some do not.

Most consumers fail to read the fine print of their policies when subscribing to a particular health plan. As a result, orthopedic practices must all too often impart the unwelcome news of what a plan will or will not cover. In many cases, the only way to know is for the practice to check with the carrier.

Even in an office setting, most supplies are considered incident to a physicians services. The supplies cannot be billed separately. If a physician bandages a knee to support it and minimize pain, the HCFA guidelines emphasize the physician is expected to have the bandage material on hand as a matter of routine practice, and its cost is included in the bill for the service (i.e., the appropriate E/M code).

In fact, the orthopedist has very few options for billing separately for supplies. Although a physician can bill for a replacement castusing the appropriate 29000-29799 series codeonly the CPT for the cast can be reported. If the patient is given materials to take home (e.g., tape) in conjunction with cast care, those supplies can be billed using the correct HCPCS code.

The complexities of billing can be staggering. If the patient is given only one roll of tape to take home and the physician ordered the tape in units of 10, the unit amount must be carefully recorded. Only the cost of one roll will be reimbursed.

Note: Patient education materialse.g., a pamphlet that thoroughly describes what to expect after total hip replacementthat cost the physician are billable using 99071 (educational supplies, such as books, tapes and pamphlets, provided by the physician for the patients education at cost to physician).

Four Extremities as Short Case Studies

1. Shoulder, Temporary Immobilizer: After falling during a soccer game, a player experiences pain in his right shoulder and goes directly to an orthopedic surgeon (OS) with the complaint. The orthopedic surgeon (OS) diagnoses a dislocated shoulder (831.00, dislocation of shoulder; unspecified) and learns shoulder dislocation is a recurring problem for the athlete. The OS schedules a surgery for repair for the next day. To support the shoulder in the interim, the OS applies a shoulder orthosis, an elastic immobilizer.

There is a HCPCS code for the immobilizer, L3670 (shoulder orthosis, acromio/clavicular [canvas and webbing type]). But the OS cannot submit the code as part of a reimbursement request because the application of the immobilizer is included in the code 23660 (open treatment of acute shoulder dislocation).

The cost of the immobilizer could be billed if it were applied by a primary care physician (PCP) who then referred the patient to the OS. And the PCP could bill it even if the OS treated the shoulder with surgery.

Even when coded correctly, L-coded items have enormous carrier discretion.

Note: Medicare claims for L codes must be sent to the Durable Medical Equipment Regional Carrier (DMERC).

2. Wrist, Cast: A woman falls while ice-skating, and breaks her own fall with the palms of her hands. In doing so, she fractures the radius in her left wrist. She goes to the clinic where her PCP refers her immediately to an on-site orthopedist who diagnoses a radial shaft fracture (ICD 813.81, fracture, radius, alone, closed) and casts it without manipulation.

The orthopedist can bill for 25500 (closed treatment of radial shaft fracture; without manipulation). Some carriers will pay for the surgical tray, using HCPCS A4550 (surgical trays). (Medicare and carriers that follow Medicare recommendations will not pay for the surgical tray in addition to 25500.)

3. Lower Leg, Cast: A young man with a lower leg cast is caught in his automobile in flood waters 1,000 miles from home. He is rescued from the car and uninjured. But because his cast has been submerged for two hours in contaminated water, a cast change is indicated.

The young mans healthcare maintenance organization gives him permission to visit a local orthopedist to have the cast replaced. The orthopedist will code for the application of the new cast, 29405 (application of short leg cast [below knee to toes]) and for the removal of the existing cast, 29700 (removal of bivalving; gauntlet, boot or body cast).

The physician can code for removal of the existing cast because he did not apply it. The cost of casting materials is included in the reimbursement for 29405.

4. Knee, Brace: A skier twists (sprains) the medial collateral ligament (717.82) of her left knee. Her orthopedist recommends conservative treatment and decides to apply a derotation knee orthosis (brace) that is molded to the patients morphology.

The CPT code for the strapping application is 29530 (strapping; knee). Because the orthopedist molds the orthosis himself, he can bill for the materials using L1840 (knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated to patient model). But carrier discretion determines whether he will receive payment for the device.