Advanced Search

Orthopedic Coding Alert

Operative Report Examination:

How to Know When Fracture Care Is an Incident-To Service

Published on Sun Dec 01, 2002

Orthopedists need not personally cast a patient's fracture to report fracture care codes as long as the physician saw the patient's fracture and made the treatment determination, you can bill the fracture care under the orthopedist's PIN, whether or not he was in the suite when his staff applied the cast.

How Practices Break Incident-To Rules

Suppose your orthopedist's operative report includes the following scenario: The orthopedist evaluates a new patient (99201-99205), refers her for a wrist x-ray (73100-73110) and asks her to return the next day to receive the x-ray results.

When she arrives the following day, the orthopedist is detained at the hospital, so a physician assistant (PA) phones the orthopedist and reads him the report. The orthopedist advises the PA to apply a gauntlet cast (29085).

The practice bills the PA's cast application as incident-to, incorrectly reasoning that the orthopedist supervised the PA and intends to dictate a note later to place in the patient's chart.

The decision to bill this scenario as incident-to poses several problems. First, "Medicare requires the physician to be on-site during incident-to billing, and in this situation, the physician was only on the telephone," says Cheryl Gueldenzopf, practice manager at Northeast Orthopedics in Tawas City, Mich. Gueldenzopf recommends that the PA bill using his own ID number when the physician is not in the suite.

The Medicare Carriers Manual (MCM), section 2051, dictates the following guidelines for billing outpatient incident-to services:

  • The physician is on-site at the time of treatment
  • The physician originally saw the patient for the first visit to the office or clinic
  • The physician sees the practice's established patients for any new medical problems.

    Fracture Care May Be Included

    A second problem with the claim described above: It should be billed as fracture care rather than as an E/M visit and a casting code, says Ron Nelson, PA-C, president of Health Services Associates Inc., a practice management consulting firm in Fremont, Mich., and past president of the American Academy of Physician Assistants (AAPA).

    "Fracture care includes the evaluation, determination of treatment and subsequent immobilization," Nelson says. "In this case, the practice is attempting to bill an E/M code and a casting code, but it's probably not possible that they can justify the separate E/M service."

    Nelson says practices that want to bill these two codes instead of one fracture care code "would have to be able to argue that the physician did additional work above and beyond what is included in fracture care, and most likely it's just not there."

    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."

    Nelson recommends billing the patient's care using one of the hand and forearm fracture care codes (25500-25695), depending on the specific bone fractured. Because the PA followed orders based on the physician's original fracture care treatment, the PA's casting can be included in the original fracture care code.

    "Many practices make the mistake of saying, 'Well, we've billed this way before and we got paid for it,' " Nelson says. "But just because you got paid for something doesn't mean you did it correctly. The carrier may have paid you, but you are still subject to an audit."

    Because carriers may view billing E/M visits and casting codes separately as "unbundling," always check with the physician before coding this way. On occasion, orthopedists perform separate and distinct E/M services with casting or splinting codes, so the physician should ultimately decide whether he performed fracture care or simple casting.

    Note: Effective Oct. 25, 2002, CMS allows incident-to billing in hospitals under certain circumstances. See our News Brief on page 94 for more information on this new ruling.

    • Other Articles in this issue of

    Orthopedic Coding Alert

    View All