DAVID STERN, MD (Practice Velocity)

Q. For splinting, our physicians use Ortho-Glass. At one time we billed out by the inch for it, but now some are saying that you cannot bill for it, as it is included in the E/M level charge. This does not make sense to me, so we’re looking for an expert opinion. Can you help me with this coding dilemma or point me in the right direction?

Question submitted by Carlene Cox, Genesis FirstCare, Ohio
A. There are specific codes for both splint application and splint supplies. Neither is included in the E/M code.
For example, if the doctor applies a short-arm fiberglass splint to an adult, then you should code:

  • Q4022: Cast supplies, short-arm splint, adult (11 years +), fiberglass
  • 29125: Application of short-arm splint (forearm to hand); static

Fracture care: If the splint is applied as the definitive care for a fracture, then you should use the CPT code for the fracture care; you should not code the CPT code for the splint application, as the initial splint or cast application is included in the code for fracture care.
If the doctor is only splinting the fracture prior to providing definitive care for the fracture, then you should code for the splint application and splint supplies.

Q. My question relates to CPT code 87880-QW (CLIA-waived rapid strep test). When coding for a pediatric urgent care center, is it appropriate to bill 87880 with the QW modifier for claims that are not sent to Medicaid or Medicare? It is my understanding that if box 23 is complete and includes the CLIA Certificate number, then this is appropriate to code utilizing the QW modifier. Please understand that when I code a chart, I am not aware of the specific payor to which the claim will be sent.

Question submitted by Diane McKenna, CCS, Holbrook, New York
A. As a general rule, modifier -QW should only be used for CLIA-waived tests when billed to Medicare, Medicaid and Tricare. In order to code accurately, you should n=modify your processes to allow you to see the payor at the time of coding, as many coding issues (not just modifiers) are specific to payors.
If your billing software automatically strips off modifier -QW when the payor does not accept this modifier, then you may be able to code this without being aware of the primary payor. In general, however, coding without knowledge of the payor will result in significant numbers of avoidable denials.

Q. We had a patient come into our hospital-affiliated urgent care center a week ago for a left forearm abscess. The physician who initially saw the patient cleaned, packed, and cultured the wound.

Yesterday, the patient came for a recheck and was seen by a different physician in our practice. The physician had to examine and repack the wound.
Are we able to charge for the physician visit, or is that an inclusive charge from the original visit? If we cannot charge for the physician visit, how do we bill for supplies?
Question submitted by Meg Bickel, ExpressCare
A. The answer to your question is quite simple, but not very satisfactory. Routine rechecks (including time and supplies for repacking) are included in the initial fee for the incision and drainage of the abscess. You should not add an E/M for the professional services of the physician. Hospital-affiliated urgent care centers that bill separately on a UB-04 form for the facility may bill for supplies on the UB-04, even during the global period for a code billed on the CMS-1500.

Q. My question is which code we could use for urgent care center while patient has chest pain and facility perform EKG?

Name withheld
A. Yes, this is the actual question that was sent by e-mail. I get scores of similar questions from people – mostly workers in foreign nations – who are actively coding for urgent care centers in the U.S.
If you have outsourced your billing to a coder who is unaware of the correct code for an EKG, you can be sure that your center is losing thousands of dollars due to poor coding in many other areas. Be very careful.

Coding for Splints, Modifier–QW, Routine Rechecks, and Language Barriers to Efficient Coding

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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