tci E/M Coding Alert - 2016 Issue 7

Reader Question: Check for Physician Involvement on Cast Removals

Question: A 10-year-old male patient presents to the emergency department (ED) for treatment of a fractured distal radius. The ED physician orders x-rays, views the films and order casting for support without reduction. The patient was sent to the “Cast Room,” where an orthopedic tech applied the cast. The emergency physician documented a level-three ED E/M. Can I report cast application separately, even though the ED physician did not apply the cast, nor is there documentation that he “supervised” the cast application? Massachusetts Subscriber Answer: Medicare rules, and the rules of payers that follow Medicare, do...

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