Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

MA PPO Host - Claim Payment Policy Bulletin

Title:

Cast and Splint Applications and Associated Supplies

Policy #:

MA00.012c

Policy

Cast and splint application, reapplication, removal, and repair for non-surgical treatments of injuries (e.g. sprains, dislocations) may be covered and eligible for reimbursement consideration by the Company.

Cast and splint applications are not eligible for separate reimbursement consideration when billed within the postoperative period of a procedure to repair an open or closed fracture. Payment is included in the global allowance of the procedure to repair an open or closed fracture.

Additionally, the reapplication, removal, and repair of a cast or splint, when performed by the same professional provider or provider group, is not eligible for separate reimbursement consideration by the Company. Payment is included in the global allowance of the procedure to repair an open or closed fracture.

The reapplication, removal, and repair of a cast or splint may be eligible for separate reimbursement consideration by the Company, when performed by a different professional provider or provider group other than the provider who initially performed the procedure to repair the open or closed fracture.

Associated supplies, listed in Attachment A of this policy, used in the application, reapplication, removal, and 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.

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

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.

Guidelines

BENEFIT APPLICATION

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

Subject to the terms and conditions of the applicable Evidence of Coverage, cast and splint application reapplication, removal, and repair, as well associated supplies (listed in Attachment A of this policy) are covered under the medical benefits of the Company’s Medicare Advantage 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.

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

CPT Procedure Code Number(s)

See Attachment A.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

See Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Attachment A: Cast and Splint Applications and Associated Supplies
Description: Procedures Related to Cast and Splint Applications and Associated Supplies

Policy History

Revisions From MA00.012c:

09/18/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
06/15/2022	This policy has been reissued in accordance with the Company's annual review process.
12/21/2020	This version of the policy will become effective 12/21/2020. The intent of the policy remains unchanged but has been updated to clarify current coverage and benefits. The following language was deleted from the policy : Walking aids, listed in Attachment A of this policy, may be eligible for separate reimbursement. The the following procedure codes associated with walking aids has been deleted from the policy: E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0130, and E0135 For Coverage and Criteria regarding these walking aids please refer to policy# MA05.044h - Durable Medical Equipment (DME)

Revisions From MA00.012b:

12/01/2017

This 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:

01/21/2015

This policy is a coding update.

Revisions From MA00.012:

01/01/2015

This is a new policy.

Version Effective Date:

01/01/2024

Version Issued Date: