Orthopedic Coding Alert

It's official: You should report either casting or fracture care, but you usually can't bill both. Version 9.2 of the National Correct Coding Initiative (NCCI), which took effect July 1, bundles scores of casting and strapping codes (29000-29590) into most fracture care codes.

The NCCI cast a wide net to bundle casting and strapping into the fracture care codes, affecting hundreds of codes in CPT's Musculoskeletal System section. For example, the edit now bars coders from reporting the upper-extremity casting codes 29000-29065 with the shoulder fracture/dislocation codes (23500-23680). Shoulder splinting (29105) and strapping (29240) are also bundled into the shoulder fracture care codes.

"Most insurance companies already bundle the initial casting code into the initial fracture treatment charge," says Betty Dively, billing supervisor at Sarasota Orthopedic Associates. She says that most fracture care claims typically include the following services:
 

  an exam (99201-99205 for new patients)
 

  an x-ray (70000 series) to diagnose the fracture
 

  fracture care (such as 25505, Closed treatment of radial shaft fracture; with manipulation)
 

  cast supplies (such as A4580, Cast supplies [e.g., plaster]).
 

Dively does not include the actual casting in her initial fracture care claim. A note in CPT's Application of Casts and Strapping section states, "A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes."
 

Report Casting Codes Sparingly

Orthopedists most commonly report the casting and strapping codes when they remove and replace a cast, either to check the fracture's healing progress or because the cast was damaged.

For example, an elderly patient with osteoporosis presents to the orthopedist 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.

Although 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]) along with the appropriate x-ray code.

It is important to show medical necessity for the cast replacement otherwise Medicare and many commercial carriers won't pay for it. You should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 29085 to tell the payer why you performed a casting service during the fracture care's global period.

If the orthopedist replaces the cast because it smells or looks dirty, payers will not reimburse the cast change unless it is so dirty that the physician fears that the patient may contract an infection. In such a case, you should carefully document that the cast could cause skin ulcers or staphylococcus.
 

Medically Necessary Procedures Get Paid

Replacing a damaged cast is usually 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."

You can also apply casting codes if another physician initially saw the patient for the fracture. "If the patient received a closed manipulation in the emergency room and then was referred to the orthopedist, we would not report fracture care," says Chris P. Galeziewski, CPC, CMIS, orthopedic coder at the Kelsey-Seybold Clinic in Houston. If, however, the patient required recasting, Galeziewski would report a casting code along with any E/M care and the x-rays.
 

NCCI Bundles Scope Into Open Surgeries

The NCCI also instituted several edits that affect newer orthopedic codes in CPT 2003. Several injection procedures such as abscess and hematoma drainage (10060-10061, 10140-10160); carpal tunnel (20526), ligament (20550) and trigger point (20552-20553); and fluoroscopy (76000-76003) are now components of the new code 20612 (Aspiration and/or injection of ganglion cyst[s] any location).

NCCI also bundles 29873 (Arthroscopy, knee, surgical; with lateral release) into its open surgical counterpart, 27425 (Lateral retinacular release, open).  

Similar edits occurred with other arthroscopic surgeries, such as 29899 (Arthroscopy, ankle [tibiotalar and fibulotalar joints], surgical; with ankle arthrodesis), which bundles into its open counterpart (27870, Arthrodesis, ankle, open).

The NCCI bundles the following shoulder procedures into new code 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair):
 

  23700* Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

  29806 Arthroscopy, shoulder, surgical; capsulorrhaphy

  29820 ... synovectomy, partial
 

  29822 ... debridement, limited
 

  29825 ... with lysis and resection of adhesions, with or without manipulation.
 
 These new edits each feature a status indicator of "1," which means that you can append modifier -59 (Distinct procedural service) to override the edits if your documentation demonstrates that you performed two separate, medically necessary services.