Q: Can you bill for splint and cast applications 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 else in the clinic. The American Medical Association (AMA) provided guidance on this in the Current Procedural Terminology (CPT) Assistant, April 2002 issue: “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.
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 and 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 E/M codes are met, then also report the appropriate level of E/M with modifier -57, “Decision for surgery” appended.
When supplying and/or applying orthoses that are described in the “Orthotic Procedures and Services” section of the Healthcare Common Procedure Coding System (HCPCS) Level II manual, the application code is built into the pricing of the codes and should not be coded separately. These codes are also known as “L-codes” because they begin with the letter “L.” Thus, if you are applying a prefabricated Velcro wrist splint, you would code L3906, “Wrist hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment.”
The Centers for Medicare and Medicaid Services (CMS) defines the different types of orthoses as follows:
- Off-the-Shelf
- Prefabricated
- May or may not be supplied as a kit
- Minimal adjustment can be done by recipient, caretaker, or supplier
- Does not require expert fitting; ie, L3908, “Wrist hand orthosis (WHO), wrist extension control cock-up, non-molded, prefabricated, off–the-shelf”
- Custom Fitted
- Prefabricated
- May or may not be supplied as a kit
- Requires substantial modification upon delivery
- Requires expert fitting by a certified orhtotist or someone with equivalent specialized training; ie, L3807, “Wrist hand finger orthosis (WHFO), without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise”
- Custom Fabricated
- Custom fabricated for one individual
- Custom measurements
- Fabrication may involve using calculations, templates, and components
- Substantial modification prior to fitting to the patient
- Requires expert fitting by a certified orhtotist or someone with equivalent specialized training; ie, L3808, “Wrist hand finger orthosis (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment”
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).
For additional information, consult the Social Security Administration’s Special Payment Rules for Particular Items and Services section on Payment for Durable Medical Equipment (https://www.ssa.gov/OP_Home/ssact/title18/1834.htm#h).