Q: I would like clarification on an article I read in The Journal of Urgent Care Medicine (JUCM) online archive. The article, Splint and Cast Application Performed by Someone Other than Physician, referenced that nonphysician staff could bill for splint and cast application. Will you please expand on the references and confirm that we can bill for splint and cast application if it is done by someone on staff other than the physician?
A: Yes, you can still bill for the service if the application is performed by someone other than the provider in the clinic. The American Medical Association (AMA) provided guidance on this in the April 2002 issue of Current Procedural Terminology (CPT) Assistant: “You will note that the reference to ‘physician’ has been retained in the clinical examples provided. This inclusion does not infer that the cast/splint/strap procedure was performed solely by the physician, as nurses or ED/orthopaedic technicians also apply casts/splints/straps under the supervision of the physician.” The narrative further explains that the use of “physician” in the clinical scenarios given is to differentiate the individual patient‒physician encounters and the procedures performed in the clinic setting.
A June 2006 CPT Assistant gave a Q&A regarding a spinal fracture treatment requiring bracing/casting. The question: Could they bill it if it was placed by someone other than the physician? The AMA response was, “In order to report the casting or strapping codes, the procedure must be performed by a physician or by other personnel under the direct supervision of a physician. As direct supervision indicates, the physician must be present during the procedure when a nonphysician is performing the splint application” (see Medicare Benefit Policy Manual Chapter 15, Section 60, available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.PDF).
Direct physician supervision means that the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.
Section 100 specifically addresses splints, casts, and other devices used for reductions of fractures and dislocations, stating that the services are covered under Medicare Part B. The section references services being performed by a physician “or other healthcare professional to the extent permissible under State law.”
Based on the references above, a nonphysician who is qualified to apply a splint or cast can perform the service as long as there is an order for the service by a physician and direct supervision by the physician. CMS further defines the term “qualified practitioner” as a physician or other individual who is:
- A qualified physical therapist or a qualified occupational therapist
- Licensed in orthotics or prosthetics by the state in which the item is supplied (in the case where the state provides licensing)
- Specifically trained and educated to provide or manage the provision of prosthetics and custom-designed or custom-fabricated orthotics, and is certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or by the Board of Orthotist/Prosthetist Certification (in the case where the state does not provide licensing)
Keep in mind, you should only bill an application code if work is involved in making the cast or splint out of materials such as plaster or fiberglass. For example, an x-ray reveals a nondisplaced fracture of the head of the right radius, initial encounter, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code S52.124A on a 10-year-old patient. You stabilize the affected extremity by applying a static, short-arm fiberglass splint and refer the patient to an orthopedist for follow-up. Since you are not providing restorative care and have referred the patient on, you can bill both for both the supplies used to make the splint as well as the application, using the following codes:
- Q4024, “Cast supplies, short arm splint, pediatric (0-10 years), fiberglass”
- 29125, “Application of short arm splint (forearm to hand); static”
If the key components for the Evaluation and Management (E/M) codes are met, then also report the appropriate level of E/M with modifier -25, “Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or service” appended.
Using the same patient example, let’s say the physician agrees to follow the patient through the healing process and the splint will be the definitive (“restorative”) treatment for this fracture. This is considered to be definitive care and the rules for billing are a little different. You can still bill for the splint supplies. In lieu of billing the splint application code, you would bill CPT code 24650, “Closed treatment of radial head or neck fracture; without manipulation” if no manipulation was required, or CPT code 24655, “Closed treatment of radial head or neck fracture; with manipulation” if manipulation was required before applying the splint.
If the key components for the Evaluation and Management (E/M) codes are met, then you may also report the appropriate level of E/M with modifier -57, “Decision for surgery” appended.