Primary Care Coding Alert

There are no bones about it: Coding for casts and strapping instead of fracture care can save your practice money and decrease denials.

"You can't bill the casting and strapping codes with the fracture care codes because casting and strapping is included in the fracture care codes," says Susan Welsh, CPC, PMCI, a coding educator and former billing coordinator for the department of orthopedics at Vanderbilt University in Nashville, Tenn. "Many coders get this confused." You can bill the casting and strapping codes only in specific situations, and you need to know when and how. Bill for Cast Replacement The most common use of the casts and strapping codes is for the removal and replacement of the cast, either to check the healing progress of the fracture or because the cast has become ineffective, Welsh says.

For example, an elderly patient with osteoporosis presents to the FP 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. While 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]).

"It is important to show medical necessity for the cast replacement, otherwise Medicare and most commercial carriers won't pay for it," Welsh says. In the example above, the physician would have to document thoroughly that the fracture needed to be checked because the cast was not providing full protection due to loss of muscle mass.

If the cast is removed and replaced because it smells or looks dirty, payers will not reimburse the visit, Welsh says. "A lot of times a child with a cast has been playing on the playground and got dirt on the cast, and it looks bad and smells bad," she says. "The physician can replace the cast, but the visit won't get paid for because it wasn't medically necessary."

Sometimes, however, the patient has soiled the cast so much that it is medically necessary because he or she is in danger of getting an infection. In such a case, you have to document carefully that the cast could cause skin ulcers or staphylococcus.

Replacing a damaged cast is also 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." The Other Physician When [...]