application of splint ( 1 for doctor and one for nurse). We do not bill
It is not appropriate to bill and E/M level for the nurse's splint application for the facility side. E/M levels require an MD's training and skill. There are great examples of what you can bill E/M levels for nursing visits in the back of your CPT book.
Then the splint CPT code can be appended to that, with a 25 modifier appended to the E/M. The nurse's work is captured in those codes.
If an elastic bandage was used to secure the splint, you would bill a HCPCS code from range A6448-A6450, depending on the size of the bandage. For example, if a short arm splint was made in the clinic from fiberglass materials for an 8-year-old, you would use HCPCS code Q4024, “Cast supplies, short arm splint, pediatric (0-10 years), fiberglass.”.
If the same splint was made for a 25-year-old, you would use code Q4022, “Cast supplies, short arm splint, adult (11 years +), fiberglass.”. In both cases, you would also assign CPT code 29125, “Application of short arm splint (forearm to hand); static” because the codes for application and strapping are not age-dependent. Q.
According to HCPCS, L3908 is defined as “Wrist-hand orthotic (WHO), wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment.”. Therefore, billing a splint application code along with this code would not be appropriate because the fitting and adjustment is included with the code.
A. CPT suggests that only the physician who provides the “restorative treatment” should code and bill for the fracture care.
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:
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.
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.
There have been several modifications of the Gartland classification over the years. For example, the Type IA has been described as a truly nondisplaced fracture and the Type IB as a minimally displaced fracture with medial column comminution or varus collapse. 6 Some clinicians distinguish between a Type IIA fracture, which is angulated with an intact hinge of bone, and a Type IIB fracture, which has a complete fracture line with displacement but with the distal fragment still touching the end of the proximal fragment. Type III injuries can also be further delineated to either posteromedial or posterolateral injuries. A recent addition to this classification is a Type IV fracture in which the distal fragment is unstable in both flexion and extension due to the loss of the periosteal attachments. 7
Fractures of the supracondylar humerus are first classified as either flexion or extension injuries.
For extension-type supracondylar humerus fractures, the surgeon uses the thumb of his/her dominant hand to reduce the distal fragment by applying an anterior force on the olecranon, while the non-dominant arm flexes the patient's arm into hyperflexion in one fluid motion (Figure 6). With posteromedial fragments, the forearm should be pronated during the reduction. With posterolateral displacement of the distal humerus, the forearm should be supinated during the reduction. As a general rule, the surgeon's thumb should point toward the side of the coronal displacement when performing the reduction. While maintaining the arm in a flexed position, the surgeon can confirm the reduction in both the coronal and sagittal planes by rotating the arm at the shoulder. Oblique views are also helpful to visualize any rotational deformity and the medial and lateral columns. For highly unstable fractures, the surgeon may want to avoid moving the arm and rotate the image intensifier around the arm board.
A supracondylar humerus fracture is an extra-articular fracture of the distal humerus at the elbow that typically occurs in children between the ages of 5 and 9 years old . This injury accounts for 50% to 70% of all elbow fractures in children and 3% to 7% of all fractures. 1,2 A supracondylar fracture of the humerus typically occurs by a fall on an outstretched hand from either furniture (beds, couches, or other objects 3-6 feet high) or playground equipment (monkey bars, slides, or swings). 3
An alternative approach to reduction of flexion injuries is to flex the elbow to 90 degrees and use the olecranon as a handle for the distal fragment. With one hand on the forearm shaft and one on the humeral shaft, all required translations and rotations can be gently applied to achieve a closed reduction. It is likely that the C-arm will have to be rotated to confirm the reduction, as rotating the arm often loses the reduction. Flexion fractures require open reduction more frequently than do extension injuries.
Figure 6. Flexion reduction maneuver for extension-type of supracondylar humerus fractures. The surgeon's dominant thumb is placed on the tip of the olecranon with the fingers on the anterior aspect of the shaft of the humerus. While the non-dominant arm flexes the arm, the dominant arm forces the distal fragment anteriorly while posteriorly directing the shaft.
With highly unstable fractures, we recommend follow-up and repeat radiographs at 1 week. If the fracture pattern is stable and the fixation is felt to be secure, we routinely have the patient follow up at 3-4 weeks with the pins and splint removed with radiographs. At this point, patients are allowed full range of motion. However, they are restricted from return to full activity until 2 months after the fixation. Final follow up is typically at 3 months to ensure alignment and range motion. If there were any underlying neuropathy with the injury, we would follow the patient until this resolved. If there is continued neuropathy 3 months after the injury, we would consider nerve conduction studies.
Putting a pin in a non-displaced fracture is coded to the root operation Insertion.
Coding Guideline B3.16: Transplantation vs. Administration#N#Putting in a mature and functioning living body part taken from another individual or animal is coded to the root operation Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section.
Editor's note: This is the fifth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.