Coding Q&A: March 2, 2004

Q: What is the correct code for elevated d-dimer when there is no more specific diagnosis given?

A: Provided this is an inpatient medical record you are referring to, and there is no other documentation for a valid diagnosis, the correct code for elevated D-dimer is 790.99 for other nonspecific findings of the blood.

D-Dimer (fragment D-Dimer, Fibrin Degradation product [FDP]) is a very specific confirmatory test for disseminated intravascular coagulation (DIC).

The fragment D-dimer assesses both thrombin and plasmin activity. D-dimer is a fibrin degradation fragment that is made through fibrinolysis. As plasmin acts on the fibrin polymer clot, FDPs and D-dimer are produced. D-dimer assay is a highly specific measurement of the amount of fibrin degradation that occurs. Normal plasma does not have detectable amounts of fragment D-dimer.

 Positive results of the D-dimer assay is more specific than the FDP assay, it is less sensitive. Therefore combining the D-dimer and the FDP test provides a highly sensitive and specific test for DIC. Levels of D-dimer can also increase when a fibrin clot is lysed by thrombosis therapy. Thrombotic conditions, such as  pulmonary infarction, deep vein thrombosis, vasoocclusive crisis of sickle cell anemia, and malignant thrombosis, are associated with high D-dimer levels.

Mary Mills, RHIT, CCS

Q: One of our surgeons performs a stapled proctopexy and hemorroidectomy with a 3-stage anal dilation with an anoscope. He does this on an ambulatory surgery basis. How would you code this? The diagnosis is circumferential mucosal prolapse and Internal hemorrhoids, and sometimes external hemorrhoids.

A: In light of the information submitted, I suggest assigning the proctopexy code 45541, and the hemorrhoidectomy code (46260, 46250, 46221, 46255-depending on the technique used). The 3 stage dilation via the anoscope is not separately reportable as it is integral to performing the proctopexy.

Glenn Krauss, RHIA, CCS, CCS-P 

Q: Now that the designation for starred procedures has been eliminated in CPT-4, is it appropriate to bill a new patient E/M code in addition to the procedure (such as wart treatment, acne surgery, etc). Our doctor often lists only the length of time the wart has been present, location and previous methods used by the patient to treat the wart, along with the physical exam of the wart. He then recommends treatment, treats the wart (17000) and instructs on follow up care.

A: This is always a tough call and in many cases when answering a question like this you will get differing opinions. As with any type of coding, if the documentation is not present we are unable to code for the service. When coding for an E/M in addition to the procedure a simple way to determine if this is "separately identifiable" is by asking "is any of the information in this note "in addition" to what is necessary to perform this procedure?" The documentation you presented is all necessary if he is to treat this wart. In my opinion you would not charge for an E/M code in addition to this procedure.

Jean Ryan-Niemackl, LPN, CPC

Q: Is it possible to code and bill the visits of psychology interns in a teaching facility? They are supervised just as psychiatric residents. I would like to bill the psychology intern's services under the supervising/teaching physician's UPIN.

A: Medicare has sent no national standard for the education or training required to bill incident to for psychology services, however, local carriers have set forth certain qualification standards in the form of an LMRP. This means that, even when performing such services "incident to" a qualified "clinical psychologists" a certain level of licensure is required in order for these services to be covered by Medicare. Because these requirements are not national requirements and are only present in LMRPs, it is important to check with your local Medicare and Medicaid carrier to see if such licensing restrictions exist.


"Incident to" services are those that are performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished "incident to" a psychologist's services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be:

1.     mental health services that are commonly furnished in a psychologist's office;

2.     an integral, although incidental, part of the professional services performed by the psychologist;

3.     performed under the direct personal supervision of the psychologist; and

4.     either furnished without charge or included in the psychologist's bill.

Furthermore, any person performing an "incident to" service must be a part-time, full-time, or leased employee of the "clinical psychologist" or an employee of the legal entity that employs the supervising "clinical psychologist".

A leased employee is a person working under a written employee leasing agreement which provides that:

·         The ancillary personnel, although employed by the leasing company, provides services as a leased employee of the "clinical psychologist" (or the entity that employs the "clinical psychologist"); and

·         The "clinical psychologists" (or their employer) exercises control over all actions taken by the leased employee with regard to the services the leased employee renders to the same extent as the "clinical psychologist" (or their employer) would exercise such control if the leased employee were directly employed by the "clinical psychologist" or the entity that employs the "clinical psychologist."

Qualifications of Ancillary Personnel

National policy does not specify the level of training or education necessary for those providing the "incident to" service. For example, these ancillary personnel could be psychology technicians, Masters level psychologists, psychology interns, or even psychologists working to complete a post-doctoral fellowship. However, there appears to be movement from local carriers to set forth certain qualification standards.

Specifically, some Medicare carriers have implemented local medical review policies (LMRPs) stating that only doctorate or masters level psychologists "when they are performing within their scope of clinical practice as authorized under State law," are qualified to perform therapeutic psychological services under the "incident to" provision. This means that, even when performing such services "incident to" a qualified "clinical psychologists" a certain level of licensure is required in order for these services to be covered by Medicare. Because these requirements are not national requirements and are only present in LMRPs, it is important to check with your local carrier to see if such restrictions exist.

Billing "Incident To" Services for Hospital Patients

HCFA issued clarification in October of 199622 stating that all "incident to" services provided to hospital inpatients or registered hospital outpatients are bundled services. According to HCFA's Hospital Manual, a hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services from the hospital. Therefore, while services provided directly by the qualified "clinical psychologists" are not bundled and are billed directly to Part B for reimbursement, the time spent by ancillary personnel (i.e., MAs, psychometrists, pre-doctoral interns and post-doctoral fellows) can only be billed by the hospital.

Supervision of "Incident To" Services

Present instructions for supervision of these services vary depending on place of service. In an office setting, the psychologist must be "somewhere in the office suite and immediately available." In an institution, however, the level of supervision is more vague. National policy states only that "being available by telephone or somewhere in the institution would not constitute direct personal supervision." Several carriers have developed more stringent requirements, particularly in Skilled Nursing Facilities (SNFs). Many of these carriers are requiring "in the room" or "over the shoulder" supervision for institutional settings. Although "incident to" services provided to hospital patients cannot be billed to Medicare Part B, this does not eliminate the "incident-to" supervision requirements.

Graduate Medical Education (GME)

Unlike psychiatry internship programs, psychology interns do not currently receive GME funding. We expect that to change in the very near future. When we are successful in attaining GME funding for our programs, it is possible that more restrictive supervision requirements may be required. Current psychiatric residency programs require the teaching physician to be present during the "key portion" of any service in which a resident is involved. This would require either direct observation of the service, or use of a one-way mirror or video equipment.23 Check with our Government Relations office to learn the latest news regarding GME.


Psychiatry: Further, the teaching physician supervising the resident must be a physician, i.e., the Medicare teaching physician policy does not apply to psychologists who supervise psychiatry residents in approved GME programs.

Medicare Carriers Manual, Transmittal 1780

Angela Carmichael, RHIA, CCS

Q: In a patient who presents to the ER with a sprain or other injury which is treated solely by the application of an Ace bandage, should this be considered a strapping? We have conflicting information: A Coding Clinic, Dec 1998, says a strapping is overlapping strips of adhesive plaster or tape, however, a question answered at himinfo.com stated that an ace bandage is NOT a strapping. We've been told to code ace bandages as strapping.

A: Before you report an initial cast/strapping with a casting and strapping code, consider the following questions:

1. Will any restorative treatment or procedure(s) (e.g., surgical repair, closed or open reduction of a fracture or joint dislocation) be performed or are they expected to be performed?

2. Will the same physician assume all subsequent fracture, dislocation or injury care?

By answering these questions you will establish a good basis for deciding if the casts and strapping codes should be reported. Based on the answers to these questions, you can then refer to the general guidelines for specific rules when making a final code determination.

Coding ED Physician Procedures

Clinical vignette

Patient A presents to the emergency department after falling off a ladder. The emergency department physician determines that the patient's left forearm is fractured. The physician then applies a short arm cast or splint and instructs the patient to follow-up with an orthopedic physician.

To code the emergency department physician's procedures for patient A, start with the two questions.

1. Has the emergency department physician performed any restorative treatment or procedure(s) or is he/she expected to perform any restorative treatment or procedure(s)?

2. Will the emergency department physician assume all subsequent FRACTURE CARE?

In the case of Patient A, the answer to both questions is no. The emergency department physician is responsible only for the initial service of casting or splinting the fractured arm. He/she will not perform, and does not expect to perform, any restorative treatment. In addition, he/she will not assume all subsequent FRACTURE CARE and has instructed the patient to follow-up with an orthopedic physician.

Therefore, the emergency department physician reports code 29075 or 29125 for the application of the initial cast or splint. If the key components for the Evaluation and Management (E/M) codes are met, then also report the appropriate level of E/M with the -25 modifier appended.

Clinical vignette

Patient B presents to the emergency department after being involved in a car accident. The emergency department physician calls an orthopedic surgeon for a consultation. The orthopedist evaluates the patient and diagnoses a sprained-knee ligament. He places a long leg cast and instructs the patient to return to his/her office for follow-up care.

To code this encounter, refer to the two questions.

1. Has the orthopedic physician performed any restorative treatment or procedure(s), or is he/she expected to perform future restorative treatment or procedure(s)?

2. Will the orthopedic physician assume all subsequent care covered by a global service period?

The answer to both questions is no. Therefore, the orthopedic physician reports the appropriate level E/M consultation code and 29345 for the application of the long leg cast.

Clinical vignette

Patient C presents to the emergency department after falling and fracturing his tibia. The emergency department physician calls an orthopedic surgeon for a consultation. The orthopedic physician evaluates the patient and performs a closed reduction of the tibia and applies a long leg cast.

In coding this example, it is important to consider that the orthopedic physician provided a restorative treatment and is responsible for subsequent FRACTURE CARE, under the surgical package. Therefore, he/she reports the E/M consultation code, provided that the key components have been met, and code 27752 for the closed reduction of the tibia. The cast application cannot be reported separately because the services described in code 27752 includes the first cast.

Consider the Facts

Remember to consider all of the facts when making the decision to use the 29000 - 29799 series of codes for initial casts/strappings. When it is not clear if the same physician who placed the cast/strapping will also provide all subsequent care, consider the following. Since an emergency department is a facility established primarily for acute care, an emergency department physician generally would not provide follow-up care for fracture, dislocation, or injury.

Typically, the role of the emergency department physician is to treat an acute problem and refer the patient to a physician of a different specialty for subsequent treatment. In most cases, the emergency department physician will be responsible only for the initial care of a fracture that does not require immediate surgery (i.e., application of the first cast/strapping). The patient is then generally referred to an orthopedic physician for all subsequent fracture, dislocation, or injury care.

Also remember that the surgical package concept, described on page 53 of CPT 1996, applies to the treatment of fracture and/or dislocation codes found throughout the Musculoskeletal System section. Therefore, only report the treatment of fracture and/or dislocation codes if the same physician is responsible for the initial cast, follow-up evaluation(s), and the management of the fracture/dislocation until healed.

If you are not sure if the same physician who treated a patient with a fracture/dislocation will also provide follow-up care, it is appropriate to ask the physician to confirm his/her role in managing the patient's care.

Coding When Surgical Treatment Is Involved

If a cast is placed following some type of restorative surgical treatment of a fracture, dislocation, or other injury (open treatment or closed manipulation) do not report the cast separately with the 29000- 29799 series of codes, as the first cast/splint or strap application is included in the treatment of fracture and/or dislocation code.

Clinical vignette

Surgical treatment is recommended for patient D who has sustained a humeral-shaft fracture. The orthopedic surgeon schedules the patient for surgery and performs open treatment of the fracture using an intramedullary implant and locking screws (CPT code 24516). Following the surgical treatment of the fracture, a cast is placed.

In this case, it is not appropriate for the orthopedic surgeon to report the placement of the cast separately, because the treatment of fracture code 24516 includes the first cast/splint or strap application.

Coding for Replacement Casts

The guideline for the use of the Casting/Strapping codes for replacement casts/strappings has not changed. As in previous years, use the 29000 - 29799 series of codes to report the application of replacement casts used during or after the period of follow-up care.

Clinical vignette

On Tuesday, patient E falls off a ladder and sustains a fracture of the tibial shaft. Treatment of the fracture, which includes the application of a long leg cast, is provided that day by Dr. A (code 27752). A week later, the cast gets wet and the patient returns to Dr. A for a replacement cast application.

In this situation it is appropriate for Dr. A to report CPT code 29355 for the replacement cast.

Coding for a Temporary Casts/Strapping

CPT 1996 includes an additional guideline for the application of temporary casts/strappings placed preoperatively. The guideline clarifies that the application of temporary cast/strapping is not considered part of the preoperative care of a procedure. Therefore, because a temporary cast/strapping is not considered part of preoperative care, use of the -56 modifier for preoperative management is not appropriate. As stated in the guidelines, a physician who applies the initial cast, strap, or splint and assumes all subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service. The first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

Clinical vignette

After playing in a football game, patient F presents to the emergency department with pain in his shoulder. An orthopedic surgeon diagnoses a fractured and dislocated shoulder, and recommends open surgical treatment. Before surgery, which is scheduled for the following day, the physician places the patient in a temporary immobilizer.

In this case, the orthopedic surgeon should not report the first immobilizer application, since this application is included in the treatment of the dislocation code 23660.

Things to Remember

Keep in mind the following information when coding casts and strapping applications of fractures, dislocations, and injuries:

If the cast/strapping is applied in the office, then supplies/materials can be billed separately using CPT code 99070 or Level 2 HCPCS codes.

If the key components of an E/M service are met at the time of a cast/strapping application, then report the appropriate level of E/M code, with the -25 modifier appended.
Coding the Evaluation of a Fracture in the Emergency Department

If the emergency department physician uses a Treatment of FRACTURE CARE code and refers the patient to an orthopedic physician for follow-up care, both physicians should work with the payers to determine payment policy guidelines.

Based on the guidelines in CPT, the physician using the Treatment of FRACTURE CARE code is reporting the service of a surgical package. From a CPT coding perspective, it is suggested that the emergency department physician report the Emergency Department Evaluation and Management code, unless a significant portion of the global FRACTURE CARE is performed by the emergency department physician. In that case, only the emergency department physician may report the treatment of FRACTURE CARE code with modifier -54 appended, for surgical care only. The unmodified treatment of FRACTURE CARE code should only be used if a physician is responsible for the initial cast, follow-up evaluation(s), and the management of the fracture until healed."

Christine Goans, CCS-P

The consultants, their companies and ADVANCE do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

Coding Clinic is published quarterly by the American Hospital Association
CPT is a registered trademark of the American Medical Association.

ICD Q & A Archives


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