At the January 2001 APC Advisory Panel meeting, the panel recommended that facilities need to be educated regarding the appropriate coding of strapping and cast application services (APCs 58 and 59). Then, at the January 2002 APC Advisory Panel meeting, another recommendation was made that education was needed regarding how to apply the appropriate codes. A workgroup, including the American Hospital Association (AHA), the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS), was convened. Under the AMA’s able leadership, a consensus article was developed and subsequently published in the AMA’s CPT Assistant, April 2002 issue. This article is a recap of that article (with a special emphasis on hospital reporting) along with additional examples to aid the hospital coder.
Hospital outpatient HCPCS codes capture facility services and resources utilized in the application of the cast, splint, or strapping performed in the emergency department or hospital outpatient clinic setting. Generally, the procedure or service is reported using a HCPCS Level I code (CPT), while drugs and supplies (separately reportable under OPPS) are reported utilizing HCPCS Level II codes where applicable.
Reporting of procedure or service
It is important to reiterate that the intent of the HCPCS Level I (CPT) casting/strapping code series 29000-29799, is the same for both physician and outpatient hospital reporting. Codes 29000-29799 are used to report:
- A replacement cast/strapping procedure
- A service performed without restorative treatment or procedures to stabilize or protect a fracture, injury or dislocation, and/or to afford pain relief to a patient; a cast/strapping service when no other treatment or procedure (specific to that injury) is performed or expected to be performed.
Reporting of supplies
HCPCS Q codes for casting supplies (Q4001-Q4051) are not reported by hospitals for cast/splint supplies. These codes are reported in the physician office setting. For hospital outpatient reporting purposes, cast/splint supply items are billed with revenue code 027X on the UB92 (HCFA 1450 form), without a corresponding HCPCS code.
According to CMS, certain other “supply” items provided to the patient, such as crutches (E0114) are considered durable medical equipment and must be billed to Medicare Durable Medical Equipment Regional Carrier (DMERC). Payment will be made by the DMERC under the CMS DME fee schedule.
Lending some clarity to splinting/strapping/casting
Splints are often used to immobilize dislocated joints and injuries (such as fractures). Splints can be made of acrylic, polyethylene foam, plaster of paris, aluminum, and splints can be made from a piece of wood or rolled paper (i.e. newspaper or magazine.
Casts protect and support broken bones, dislocated joints, and injured soft tissue, such as tendons and ligaments. Casts are usually made of plaster or fiberglass. Fiberglass weighs less than plaster, is more durable and allows the skin more adequate airflow than plaster.
Strappings are defined as the application of strips of bandages (adhesives), one overlapping the other, to cover and exert pressure upon an extremity or other area of the body. Some strappings are customized to reinforce and support ligament structures through restriction of movement for increased stabilization.
Slings and Ace (gauze/elastic) bandages are often utilized to support a fracture or other injury. They are often used along with a cast or splint. Application of slings and Ace (gauze/elastic) bandages without a corresponding cast or splint is considered part of the facility charge.
Post-op shoe is a medical or surgical post-operative shoe that provides improved support to the foot during the healing process, as well as assisting in facilitating early ambulation. The application of the post-op shoe is considered part of the procedure and would not be separately reportable. The cost for the post-op shoe is billed as a supply with revenue code 027X.
Let’s ask the editor
Note: At the present time, there is no standard mapping of Evaluation and Management (E/M) codes for facility billing of emergency department or outpatient clinic visits. Therefore, no specific E/M codes have been assigned to the examples below.
This is a 53-year-old male who is seen in the emergency department (ED) after a fall. The patient was evaluated and x-rays were ordered. On review of the x-rays the emergency department physician determined that the patient sustained a nondisplaced fracture of the distal left ulna.
Due to the swelling, a plaster-molded splint was applied for immobilization and protection of the fracture. The patient is referred to the orthopedic clinic for follow-up treatment in two days. What are the code assignments for this encounter?
This patient is a 65-year-old female who presents to the hospital orthopedic outpatient clinic for a one-week follow-up of a displaced right patella. The right long-leg cast was removed due to poor fitting from reduced swelling. The orthopedist evaluated the patient and applied a cylinder fiberglass cast. What are the appropriate codes for this encounter?
This patient is seen in the emergency department for an injury to her left shoulder following a motor vehicle accident. X-rays were taken and the results showed a humeral shaft fracture. A closed reduction with manipulation of the humeral shaft was ordered. Following the treatment of the fracture, a cast was placed. The patient will be seen in the outpatient orthopedic clinic in 2 weeks. What code(s) would be reported for this case?
Code 24505-LT—Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction for the treatment of the fracture.
Code 73060-LT—Radiological examination; humerus, minimum two views, for the x-rays of the humerus.
The initial placement of the cast in included in the code for the treatment of the fracture. Report the appropriate E/M code for the emergency department, plus the associated supplies, and pharmacy charges.
This 39-year-old patient was seen in the emergency room with complaints of stabbing pain at her elbow. She stated that while reaching to catch her 3-year-old son falling from a chair she felt a stabbing pain around her elbow. Now she can barely lift her right arm without experiencing pain. X-rays of her right elbow were taken. The emergency physician documented a diagnosis of acute muscle strain. A sling was applied. Instructions were given not to do any heavy lifting and to follow up with her doctor in a week. What are the appropriate code assignments for this case?
73070-RT—Radiological examination, elbow; two views.
In addition, add the appropriate evaluation and management (E/M) code for the clinic visit. Plus the associated supplies, and pharmacy charges. The application of the sling may be considered in determining the E/M facility level charge.
Is the application of a bandage ever considered the same as a strapping?
Some bandaging would be considered the same as a strapping where the bandages are applied for coverage and pressure on an extremity or another area of the body, one overlapping the other. Most strappings are customized to provide structured reinforcement and support to ligament structures for increased stabilization.
Other strappings such as an Ace (gauze/elastic) bandage would be considered the same as a dressing. Ace bandages are often used along with a cast or splint and are not separately reportable.