Fracture Treatments & Cast application

Correctly coding casts, splints, and strapping can be confusing. Much of the confusion is related to what type of materials are classified as casts, splints, or strapping; whether the CPT application codes or the HCPCS level II codes should be assigned; and whether the work performed is included in E/M codes.

This article provides general guidance and suggested best practices for sorting out these issues.

Defining Treatment Modality

A cast is a “rigid dressing, molded to the body while pliable and hardening as it dries,” that provides firm support; it does not allow movement. ¹ A splint is any stiff device attached to a limb in order to discourage movement. There are two types of splints: static or dynamic. ² Static splints provide full immobilization, while dynamic splints allow some movement. ³

Strapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure and hold a structure in place. ⁴

Basic Rules

One of the first principles of coding casts, splints, and strapping is to understand when a separate code can be reported in relation to a restorative treatment or procedure code. Coders should ask themselves the following questions before reporting an initial casts/splints/strapping code:

Will any restorative treatment or procedure be performed or is one expected to be performed (e.g., surgical repair, closed or open reduction of a fracture, or joint dislocation)?
Will the same physician assume all subsequent fracture, dislocation, or injury care?

The answers will aid coders in deciding if casts/splints/strapping codes should be reported. Final code determination should be based on the specific rules in the general guidelines preceding the application of casts and strapping heading in the CPT book.

Examples of how these guidelines should be applied in facility and physician office settings are outlined below.

ED Visit

A patient is diagnosed with an ankle fracture in the emergency department. The physician applies a short leg cast and refers the patient to an orthopedist.

If the physician applies the cast, coders should 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.

Orthopedic Visit

The same patient presents to the orthopedist for definitive treatment. Closed reduction with manipulation is performed and a cast applied.

Coders should report the CPT code for closed treatment of the fracture only, because cast application is integral to any definitive fracture treatment. The physician may report supplies with the appropriate Q codes.

If the closed reduction had been performed in the emergency department, the facility would only assign codes for the treatment and the supply, if applicable, but not for the application of the cast.

If the same physician will not provide follow-up care, modifier 54 should be assigned to the CPT code, and the second physician who provides the follow-up care (involving more than just cast or splint removal or replacement) should assign the same code with modifier 55.

The patient returns to the same physician for follow-up care, and the physician replaces the cast. The physician can report the code for the application of the cast and supplies. CPT allows separate coding and charging of any follow-up care related to the condition and devices used, including application of casts, splints, or strapping if definitive treatment has already been performed.

The same patient then returns to the same physician, who removes the cast. The physician may not report the removal of cast, because the removal by the same physician or a physician in the same physician group is included in the application code. The removal of cast codes may only be assigned when a different physician in a different physician group removes the cast.

The intent of the CPT casts/splints/strapping code series is the same for both physician and outpatient hospital reporting; however, carriers and fiscal intermediaries have established different guidelines for facilities and physicians. The following discussion outlines what is considered best practice guidelines for each setting.

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