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Fracture care or EM coding for fracture treated with OTC splint?

  1. #1
    Default Fracture care or EM coding for fracture treated with OTC splint?
    Medical Coding Books
    If a patient presents with a fracture and the ortho decides that the best care is an over the counter type splint/brace that simply velcros on, should fracture care be coded or simply EM?

  2. #2
    Default
    Here is an article on the aaos.com website:

    According to CPT, the following reference supports reporting the services using an E&M code and the appropriate cast/splint application code as applicable. ?If cast application or strapping is provided as an initial service (eg, casting of a sprained ankle or knee) in which no other procedure or treatment (eg, surgical repair, reduction of a fracture or joint dislocation) is performed or is expected to be performed by a physician rendering the initial care only, use the casting, strapping and/or supply code (99070) in addition to an evaluation and management code as appropriate.? Supplies would be reported using the appropriate A (nonMedicare) or Q (Medicare and other payors requiring Q) codes.

    I worked short term for an ortho group that would always bill fracture care codes even in situations like this which I felt was wrong because of the high possible out of pocket cost to the patient AND the improper coding. The aaos.com website has alot of helpful articles and most of them can be viewed for free- a plus!!
    Teresa Kelley, CPC
    Detroit, MI AAPC Chapter member

  3. #3
    Location
    Hartford, CT
    Posts
    723
    Default
    Teresa's answer is incomplete, the same CPT guidelines go on to state "An individual 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 initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes."

    The above referenced aaos articles do not state which billing method is preferred over the other, it is basically up to the provider to decide which codes to use. I've had patients complain about both methods (using fracture codes and using E/M) If you use the fracture codes, they complain about the charge even though they have 90 follow up, if you use the E/M codes they complain because they have to pay a copay each time the come for follow-up.

    The whole matter comes down to what the doctor wants to use. (S)he may feel that because they are taking responsibility for the treatment of the fracture no matter what type of splint/strap or cast is decided on that the fracture codes should be used. Some doctors decided based on the severity of the fracture or location (i.e. toe or finger E/M, larger bones fracture code). It's entirely up to the provider who is caring for the patient. You should discuss this with your doctor and find out what his/her perspectives are.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  4. #4
    Location
    Buffalo, NY
    Posts
    40
    Default Fracture treated with OTC splint
    I code for an urgent care facility. If our providers apply and OTC splint can we code for splint application or is it included in the OTC splint? We do not bill the HCPCS code, I believe our DME supplier bills directly.

    We have been going back and forth on this for months, so any direction would be greatly appreciated!
    Jackie M, CPC

  5. #5
    Default
    Just started at an ortho clinic. We only see referrals. If this was a new patient sent by PCP, we would code 99203 then appropriate Fx code ending in A. If any cast or splint was used in house, then the 25 modifier would be appended as well at the lateral code for the splint/cast. If it was a current patient previously seen for initial Fx then the code would be 99213 and the Fx code would end in either D,G, P, or S depending on healing circumstances as well as time after initial Fx.

    Peace
    @_*
    Hope that helps.

  6. Default
    Based on my personal experience as an Orthopedic Surgeon, and in working with the Billing and Coding Department of our Multi-specialty Clinic, my Coders advised me several years ago that many payers at that time did not even recognize or pay for Fracture Care Codes for "Closed Treatment of ..... fracture without manipulation." As such, they recommended charging the appropriate E&M code for the level of service. Of course, a diagnosis code would have to be used and accurate. In these scenarios, the application of a Cast, Splint, or Off the Shelf Prefabricated Splint/Device could be charged for with Modifier 25 for materials and application. We had separate charges for application and materials, again with the appropriate Modifier. This would apply to an Initial Evaluation by the Surgeon when the patient had not been seen or treated elsewhere (ER, Walk-in Clinic, etc.). If the patient had prior E&M elsewhere and came in with a Cast, Splint, or Off the Shelf Device in place, then you wouldn't charge for materials and application if there was no change in the treatment plan. If the Surgeon on first evaluation decided to use a different method of external immobilization, i.e. a change of treatment plan, and applied something else, then the materials and application could be charged for.

    By using a Fracture Treatment Code for these cases, for which you may or may not be compensated, you are tied to a Global Fee time frame, pretty much the 90 day time period. With that, you can only charge for follow up Xray studies and interpretation, and for Cast, Splint, or Off the Shelf Devices when a change is warranted due to wear or "no longer fits" well enough to provide the required immobilization support, etc. The subsequent office visits are not charged for. Furthermore, these Fracture Treatment Codes generally include the application and materials of the Cast, Splint, Device used, so you may not be successful in getting paid for them when it is the Initial Evaluation and Treatment.

    My "advisors" told me to use the E&M Codes, etc. as above when these occasions occurred as we were more likely to get paid something for visits, casts etc., and X-ray studies than by using Fracture Codes. You would have to know what the particular patient's payer is going to recognize and cover. The patients are not necessarily be happy with the multiple office charges for each visit, but you have to go the route that is going to get you paid.

    Respectfully submitted, Alan Pechacek, M.D.
    icd10orthocoder.com

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