Benefit Payment Guideline Casting and Dressing Application Benefit Policy Statement: The use of casting, splinting or strapping may be considered medically necessary for a patient who has experienced a fracture, dislocation or who has ligamentous instability following an acute injury, or as the result of a disease or surgery. HealthyCT covers and considers for reimbursement cast and dressing applications and associated supplies provided in the office setting. _______________________________________________________________________________________________________________________ Benefit Policy Guidelines: Application of casts and dressings is covered after the applicable Cost-Share amount. The Cost-Share amount depends on where the services are provided. Supplies that are used for recasting or re-splinting are eligible for separate reimbursement when the service is performed in the office setting by an orthopedist, internist, podiatrist, pediatrician, general practitioner, family practitioner, or primary care practitioner (PCP). LOB: Commercial – On exchange and off exchange ☒Large group ☒Small group ☒Individual Provider Guidelines: Initial Application 1. The initial application of a cast or splint is eligible for separate reimbursement from the evaluation and management service (E/M), except when the initial application is associated with fracture care or follows surgery. In such cases, the initial application and the E/M are included in the surgical fee. Proprietary and Confidential Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change. Casting and Dressing Application: Approved at 8/8/2014 PCP committee meeting 2. Additional evaluation and management services are reportable only if significant identifiable further services are provided at the time of the cast application or strapping. In these cases, further review of a claim and supporting documentation may be necessary to make the appropriate reimbursement decision. Reapplication and supplies 1. The professional component for the reapplication of a cast or splint is eligible for separate reimbursement from the E/M when provided in the office setting, with the following exception: When the reapplication of a cast or splint follows a surgical procedure or fracture care, the professional component is considered part of the surgical fee and is not eligible for separate reimbursement Removal or Repair 1. Codes for cast removals should be only used for casts applied by another individual. If the cast was applied by the same practitioner, the codes for removal should not be billed. This is because the codes in the “Application of Casts and Strapping” series include the cast removal as well as the application. Code Description: See Attachment A for list of applicable codes* The following HCPCS Level II category A codes represent general codes and should not be reported because there are specific codes in the HCPCS level II categories (i.e.: E-codes, L-codes, and Q-codes) for splints and casting supplies. This is consistent with CMS correct coding guidelines. Splints – A4570 Cast supplies (e.g.: plaster) – A4580 Special casting material (e.g.: fiberglass) – A4590 Examples of Claim Adjudication Scenarios: Example 1: Member seen by PCP in office with an injury to her finger. After evaluating Member the practitioner decides the patient has a sprained intraphalangeal joint and applies a splint to the patient’s finger. Appropriate to bill the initial splinting code along with an E&M code and the appropriate Q code. Example 2: An emergency room practitioner examines a patient who reports with a closed humeral shaft fracture. The patient is also complaining of a headache and chest pain. The practitioner treats the arm but also conducts a Proprietary and Confidential Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change. Casting and Dressing Application: Approved at 8/8/2014 PCP committee meeting level–four E/M service to determine the cause of the head and chest pain. The fracture care code and the E/M code (with the appropriate modifier _25) should be paid separately. Example 3: Emergency Room Visit-A patient is diagnosed with an ankle fracture in the emergency department. The practitioner applies a short leg cast and refers the patient to an orthopedist. If the practitioner applies the cast, Report the code for the application of the cast. If the hospital staff applies the cast, the facility will report the same code. The facility should also charge for the supply, as appropriate. Example 4: Orthopedic Visit-The same patient presents to the orthopedist for definitive treatment. Closed reduction with manipulation is performed and a cast applied. The practitioner should report the CPT code for closed treatment of the fracture only, because cast application is integral to any definitive fracture treatment. The practitioner may report supplies with the appropriate Q codes. Example 5: Follow-up Visit: The same patient then returns to the same practitioner, who removes the cast. The practitioner may not report the removal of cast, because the removal by the same practitioner or a practitioner in the same practitioner group is included in the application code. The removal of cast codes may only be assigned when a different practitioner in a different practitioner group removes the cast. Exclusions N/A (except those listed in the Provider guidelines) References AMA CPT Certificate of Coverage Nelson, Tanai S.; Benjamin, Christina. "Casting Conundrum: Correct Coding for Casts, Splints, and Strapping " Journal of AHIMA 80, no.7 (July 2009): 74-76. Document History 08/08/2014 03/31/2016 Initial Version Removed deleted CPT codes 29020, 29025. Added CPT codes 29000, 29582, 29583, 29584 Proprietary and Confidential Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change. Casting and Dressing Application: Approved at 8/8/2014 PCP committee meeting Attachment A Casting and Dressing Application Benefit Guidelines CPT CODES Cast Application: 29000, 29010, 29015, , 29035, 29040, 29044, 29046, 29049, 29055, 29058, 29065, 29075, 29085, 29086, 29305, 29325, 29345, 29355, 29358, 29365, 29405, 29425, 29435, 29440, 29445, 29450 Splint Application: 29105, 29125, 29126, 29130, 29131, 29505, 29515 Strapping Applications: 29520, 29530, 29540, 29550, 29580, 29581, 29582,29583,29584, 29200, 29240, 29260, 29280 Removal and Repair: 29700, 29705, 29710, 29715, 29720, 29730, 29740, 29750, 29799 Cast and Splint Supplies: Codes Narrative Description Q4001 Casting supplies, body cast adult, with or without head, plaster Q4002 Cast supplies, body cast adult, with or without head, fiberglass Q4003 Cast supplies, shoulder cast, adult (11 years +), plaster Q4004 Cast supplies, shoulder cast, adult (11 years +), fiberglass Q4005 Cast supplies, long arm cast, adult (11 years +), plaster Q4006 Cast supplies, long arm cast, adult (11 years +), fiberglass Q4007 Cast supplies, long arm cast, pediatric (0-10 years), plaster Q4008 Cast supplies, long arm cast, pediatric (0-10 years), fiberglass Q4009 Cast supplies, short arm cast, adult (11 years +), plaster Q4010 Cast supplies, short arm cast, adult (11 years +), fiberglass Q4011 Cast supplies, short arm cast, pediatric (0-10 years), plaster Q4012 Cast supplies, short arm cast, pediatric (0-10 years), fiberglass Q4013 Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster Q4014 Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass Q4015 Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster Q4016 Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), fiberglass Q4017 Cast supplies, long arm splint, adult (11 years +), plaster Q4018 Cast supplies, long arm splint, adult (11 years +), fiberglass Q4019 Cast supplies, long arm splint, pediatric (0-10 years), plaster Q4020 Cast supplies, long arm splint, pediatric (0-10 years), fiberglass Q4021 Cast supplies, short arm splint, adult (11 years +), plaster Q4022 Cast supplies, short arm splint, adult (11 years +), fiberglass Q4023 Cast supplies, short arm splint, pediatric (0-10 years), plaster Q4024 Cast supplies, short arm splint, pediatric (0-10 years), fiberglass Q4025 Cast supplies, hip spica (one or both legs), adult (11 years +), plaster Q4026 Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass Q4027 Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster Q4028 Cast supplies, hip spica (one or both legs), pediatric (0-10 years), fiberglass Q4029 Cast supplies, long leg cast, adult (11 years +), plaster Q4030 Cast supplies, long leg cast, adult (11 years +), fiberglass Q4031 Cast supplies, long leg cast, pediatric (0-10 years), plaster Q4032 Cast supplies, long leg cast, pediatric (0-10 years), fiberglass Q4033 Cast supplies, long leg cylinder cast, adult (11 years +), plaster Q4034 Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass Q4035 Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster Q4036 Cast supplies, long leg cylinder cast, pediatric (0-10 years), fiberglass Q4037 Cast supplies, short leg cast, adult (11 years +), plaster Q4038 Cast supplies, short leg cast, adult (11 years +), fiberglass Q4039 Cast supplies, short leg cast, pediatric (0-10 years), plaster Q4040 Cast supplies, short leg cast, pediatric (0-10 years), fiberglass Q4041 Cast supplies, long leg splint, adult (11 years +), plaster Q4042 Cast supplies, long leg splint, adult (11 years +), fiberglass Q4043 Cast supplies, long leg splint, pediatric (0-10 years), plaster Q4044 Cast supplies, long leg splint, pediatric (0-10 years), fiberglass Q4045 Cast supplies, short leg splint, adult (11 years +), plaster Q4046 Cast supplies, short leg splint, adult (11 years +), fiberglass Q4047 Cast supplies, short leg splint, pediatric (0-10 years), plaster Q4048 Cast supplies, short leg splint, pediatric (0-10 years), fiberglass Q4049 Finger splint, static Q4050 Cast supplies, for unlisted types and materials of casts Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies) S8450 Splint, prefabricated, digit (Specify digit by use of modifier) S8451 Splint, prefabricated, wrist or ankle S8452 Splint, prefabricated, elbow Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed above are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.
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