MA PPO

Cast and Splint Applications and Associated Supplies Provided in the Office Setting
MA00.012b


Policy

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.

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

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


Coding and Billing Requirements



Policy History

12/1/2017
12/1/2017
MA00.012
Claim Payment Policy Bulletin
Medicare Advantage
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Yes