Health Information Management

Reporting splints with CPT and L codes

APCs Insider, June 24, 2011

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Q: An insurance company that follows APC guidelines recently denied a large number of our claims because it said we duplicated services for splinting procedures in the ED. We reviewed the claims and determined that we reported a CPT® code for the procedure and a HCPCS L code for the splint. We have discussed this with the insurer, but it refuses to reverse the denial. Can you help us?

A: HCPCS L codes describe orthotics and prosthetics, which includes codes for some splints and immobilizers. The definition of many L codes includes the phrase, “includes fitting and adjustment.” Therefore, when you report the L code, you are reporting the splint and the procedure of fitting the device to the patient. When you also report a CPT® code, you report the procedure twice.
CMS published information about its APC policy for reporting HCPCS codes for orthotic devices in an April 2009 update. Transmittal 1702 states: 

When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patient’s use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services. Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services. For example, if the hospital outpatient staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code to describe the fitting and adjustment.

APC guidelines support the reporting of an L code for a device that includes fitting and adjusting the device.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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