Notification

Cast and Splint Applications and Associated Supplies Provided in the Office Setting


Notification Issue Date: 09/01/2017

This version of the policy will become effective 12/01/2017.

HCPCS codes A4570, A4580, and A4590 represent general codes and are no longer eligible for reimbursement consideration. See Attachment A for a list of specific eligible codes.



Medicare Advantage Policy

Title:Cast and Splint Applications and Associated Supplies Provided in the Office Setting
Policy #:MA00.012b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company covers and considers for reimbursement cast and splint applications and associated supplies provided in the office setting.

The application of a cast or splint may be eligible for reimbursement when an open or closed fracture treatment procedure or surgery is not performed.

The application of a cast or splint is not eligible for separate reimbursement when billed within the postoperative period of an open or closed fracture treatment procedure or surgery. Payment for the application of a cast or splint is included in the global allowance of the open or closed fracture treatment procedure or surgery.

The reapplication, removal, or repair of a cast or splint are included in the global allowance of the open or closed fracture treatment procedure or surgery when performed by the same professional provider or a professional provider in the same provider group.

The reapplication, removal, or repair of a cast or splint may be eligible for separate reimbursement when performed by a different professional provider or group who initially performed the open or closed fracture treatment procedure or surgery.

Associated supplies, listed in Attachment A of this policy, used in the application, reapplication, removal, or repair of a cast or splint may be eligible for separate reimbursement.

The following HCPCS codes represent general codes and are not eligible for reimbursement consideration.
  • Splints – A4570
  • Cast supplies (e.g., plaster) – A4580
  • Special casting material (e.g., fiberglass) – A4590

The initial application of a localizer jacket following scoliosis surgery may be eligible for separate reimbursement.

Walking aids, listed in Attachment A of this policy, may be eligible for separate reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

Subject to the terms and conditions of the applicable benefit contract, services that are outlined in Attachments A are covered under the medical benefits of the Company’s products.

BILLING GUIDELINES

Primary care providers (PCPs) who receive a monthly capitation are reimbursed above capitation for walking aids and casting and splinting supplies when provided in the office setting.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Rigid immobilization refers to the process of holding a joint or bone in place with the use of a cast or splint. This is done to prevent an injured area from moving while it heals. The devices are firm (e.g., plaster, fiberglass) and not intended for self-removal.

Casts are generally used for the treatment of fractures, dislocations, and/or other musculoskeletal injuries. Splints are often used to immobilize a fractured or dislocated bone, or to maintain any part of the body in a fixed position.

Fracture care is the treatment of an open or closed fracture (broken bone) by performing a non-operative and/or operative technique. The non-operative technique is the treatment of a fracture typically with the use of a cast or splint and does not require surgery. While some bones can heal with the use of a cast or splint and do not require surgery, others may require a more invasive operative technique.

Walking aids are devices that are used to facilitate the physical movement of a person from one place to another in the event that they are unable to do so without assistance.
References

Evidence of Coverage


Coding

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 below 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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Cast and Splint Applications and Associated Supplies Provided in the Office Setting






Policy History

Revisions from MA00.012b:
12/01/2017This version of the policy will become effective 12/01/2017.

The following HCPCS codes have been added to this policy: E0117, E0118

HCPCS codes A4570, A4580, and A4590 represent general codes and are no longer eligible for reimbursement consideration. See Attachment A for a list of specific eligible codes.

Revisions from MA00.012a:
01/21/2015This policy is a coding update.

Revisions from MA00.012:
01/01/2015This is a new policy.




Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A