Section 20-2-IV - MUSCULOSKELETAL SYSTEMA.Casting and Strapping. This applies to severe muscle sprains or strains that require casting or strapping. 1. Initial (new patient) treatment for soft tissue injuries must be billed under the appropriate office visit code.2. When a cast or strapping is applied during an initial visit, supplies and materials (e.g., stockinet, plaster, fiberglass, ace bandages) may be itemized and billed separately using the appropriate HCPCS code.3. When initial casting and/or strapping is applied for the first time during an established patient visit, reimbursement may be made for the itemized supplies and materials in addition to the appropriate established patient visit.4. Replacement casts or strapping provided during a follow-up visit (established patient) include reimbursement for the replacement service as well as the removal of casts, splints, or strapping. Follow-up visit charges may be reimbursed in addition to replacement casting and strapping only when additional significantly identifiable medical services are provided. Office notes should substantiate medical necessity of the visit. Cast supplies may be billed using the appropriate HCPCS code and reimbursed separately.B.Fracture Care1. Fracture care is a global service. It includes the examination, restoration or stabilization of the fracture, application of the first cast, and cast removal. Casting material is not considered part of the global package and may be reimbursed separately. It is inappropriate to bill an office visit since the reason for the encounter is for fracture care. However, if the patient requires surgical intervention, additional reimbursement can be made for the appropriate E/M code to properly evaluate the patient for surgery. Use modifier 57 with the E/M code.2. Reimbursement for fracture care includes the application and removal of the first cast or traction device only. Replacement casting during the period of follow-up care is reimbursed separately.3. The phrase "with manipulation" describes reduction of a fracture.4. Re-reduction of a fracture performed by the primary physician may be identified by the addition of modifier 76 to the usual procedure code to indicate "repeat procedure" by the same physician.5. The term "complicated" appears in some musculoskeletal code descriptions. It implies an infection occurred or the surgery took longer than usual. Be sure the medical record documentation supports the "complicated" descriptor to justify reimbursement.C.Bone, Cartilage, and Fascia Grafts1. Reimbursement for obtaining autogenous bone, cartilage or fascia grafts, or other tissue through separate incisions is made only when the graft is not described as part of the basic procedure.2. Tissue obtained from a cadaver for grafting must be billed using code 99070 and accompanied by a report..D.ArthroscopyNote : Diagnostic arthroscopy is considered to be included in a surgical arthroscopy. Only in the most unusual case is an increased fee justified because of increased complexity of the intra-articular surgery performed.
1. Diagnostic arthroscopy will be reimbursed at fifty percent (50%) when followed by open surgery.2. Diagnostic arthroscopy is not billed when followed by arthroscopic surgery.3. If there are only minor findings that do not confirm a significant preoperative diagnosis, the procedure should be billed as a diagnostic arthroscopy.E.Arthrodesis Procedures. Many revisions have occurred in CPT coding for arthrodesis procedures. References to bone grafting and fixation are now procedures which are listed and reimbursed separately from the arthrodesis codes. To help alleviate any misunderstanding about when to code a discectomy in addition to an arthrodesis, the statement "including minimal discectomy" to prepare interspace has been added to the anterior interbody technique. If the disk is removed for decompression of the spinal cord, the decompression should be coded and reimbursed separately.
F.External Spinal Stimulators Post Fusion1. Pre-certification is required for use of the external spinal stimulator.2. The following criteria are established for the medically accepted standard of care when determining applicability for the use of an external spinal stimulator. However, the medical necessity should be determined on a case-by-case basis.a. Patient has had a previously failed spinal fusion; and/orb. Patient is scheduled for revision or repair of pseudoarthrosis; and/orc. The patient smokes greater than a pack of cigarettes per day and is scheduled for spinal fusion.3. The external spinal stimulator is not approved by MWCC for use in primary spinal fusions.4. When medical necessity is established based on the above criteria, the external spinal stimulator will be reimbursed according to the MAR in the Fee Schedule.G.Carpal Tunnel Release. The following intraoperative services are included in the global service package for carpal tunnel release and should not be reported separately and do not warrant additional reimbursement: * Surgical approach;
* Isolation of neurovascular structures;
* Video imaging;
* Stimulation of nerves for identification;
* Application of dressing, splint, or cast;
* Tenolysis of flexor tendons;
* Flexor tenosynovectomy;
* Excision of lipoma of carpal canal;
* Exploration of incidental release of ulnar nerve;
* Division of transverse carpal ligament;
* Use of endoscopic equipment;
* Placement and removal of surgical drains or suction device; and
* Closure of wound.