Reimbursement for Total Contact Casting: Fighting The Financial Burden

Disclaimer: Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

The care of wounds represents a significant portion of healthcare spending. In 2008, more than 89 million people in the US were treated for wound conditions that accounted for costs in excess of $25 billion.1 Access to efficacious therapies for the treatment of one common wound type, diabetic foot ulcers, is essential to help contain healthcare spending and to ensure optimum outcomes for persons suffering with these wounds. However, access to effective treatments can be restricted depending on where the patient lives, where and by whom care is provided, or by the payer’s coverage criteria.2-5
The financial burden of diabetic foot ulcers is considerable. An uncomplicated diabetic foot ulcer is estimated to cost $8,000 to treat. An infected ulcer can cost $17,000 and the cost of amputation can reach $45,000.6,7 In 2007, more than 100,000 people with diabetes in the US had a foot amputation.8
Use of Total Contact Casting (TCC) results in a greater percent of diabetic ulcers healing in a shorter time. Many clinical studies and most randomized, controlled comparative studies have demonstrated improved healing rates and cost savings when compared to standard methods of care for diabetic foot ulcers without TCC.9-20 Reducing the time a diabetic wound is open can help reduce the risks of complications such as infection or amputation. These dramatically increase the cost of care and can negatively impact a person’s life. Many clinical Guidelines and treatment protocols 21, 22 recommend the use of TCC for the management of diabetic foot ulcerations.

Coding for TCC

The application of a TCC is identified by Current Procedure Terminology (CPT®) code, CPT 29445 [application of a rigid total contact cast, half leg, adult]. Physicians and other qualified healthcare professionals utilize CPT® 29445 to bill for this service. CPT® codes are used by all payers for physician services provided in hospitals, clinics and other settings, including the physician office.

Unlike most CPT® codes, the American Medical Association has not included the cost of casting materials in the practice expense relative value unit (PE-RVU) calculation used by Medicare and other payers to establish a payment fee for applying TCC. Therefore, in a physician office where the physician incurs the expense of the casting supplies, the supplies are always separately billable, whether it is the first or subsequent cast application. Physicians use the appropriate Healthcare Common Procedural Coding System (HCPCS) codes for casting supplies [Q4001-Q4051] when reporting their service for the TCC application on billing claims.

Application of TCC is a customized technique based on the location of the ulcerations(s), fracture(s), or surgical wound site(s). The application process includes management of the diabetic ulcer wound site, if present, along with the application of protective stockinet and dense padding layers over tibial, malleolar, foot and toe surfaces. This is followed by layers of plaster and fiberglass casting materials and splints for rigidity. Rigid support foot plate and walker heel or an external rigid splint boot is applied for ambulation. Each of these components is identified by a HCPCS code. Physicians should bill per unit/roll of casting material utilized to complete the application of TCC. With some of the more advanced TCCs, where new innovative casting materials are used to reduce the complicated technique of the older casts, the cast sleeve material is equivalent to the use of 3 rolls of fiberglass.

Coding/Payment in the Hospital-based Outpatient Clinic

In the hospital-based outpatient clinic, physicians continue to bill for his/her service for application of a TCC using CPT® code 29445 and the facility bills for the casting supplies. For Medicare, procedure services provided in this setting are captured under Ambulatory Payment Classification (APC) codes. These are group codes for similar procedures that are paid a single rate. Medicare assigns a payment rate for each APC that is paid to the facility. If more than one procedure is required during an outpatient clinic visit, usually the second or subsequent procedures are paid 50% of the full fee level. Other payers reimburse a facility by CPT® code or other level-based payment for services.

Medicare payment to a hospital-based outpatient clinic is based on APC 426 Level II Strapping and Casting, which includes CPT® code 29445 for the application of rigid, half leg cast. If the diabetic wound also requires other procedures, such as surgical or selective debridement [CPT® 11041-44, 97597-98], wound ultrasound [CPT® 0183T], or a skin graft procedure [CPT® 15002-15431] before the application of a TCC, then each procedure is identified by either an APC or CPT® code and billed to the payer.

Reimbursement Issues

Unfortunately, many clinicians are experiencing inconsistency in coverage and payment for application of the TCC procedure. In the outpatient clinic setting, some claims are being denied because of a misunderstanding of Total Contact Casting. Some clinicians and clinics have received denials when the TCC procedure follows a surgical debridement (CPT® 11040-11044) and/ or the application of skin substitute graft (CPT® 15170-15431). These denials suggest the payers are incorrectly considering the TCC application following a graft surgical procedure or debridement as a ‘dressing or bandage’ and not a separate, distinct casting procedure. Debridement and/or application of skin substitute grafts, if indicated along with the application of a TCC, are distinct procedures and are recognized as Standard of Care for the treatment of diabetic/neuropathic ulceration of the foot.

Additionally, some payers are inconsistent in the number of cast supply units they approve for reimbursement to the physician when a TCC is applied in the office. As mentioned above, physicians bill for the casting supplies, identified by HCPCS codes, along with the application procedure for reimbursement.
These inconsistencies in reimbursement have created a situation where a physician is reluctant to apply TCC in his/her office when there is uncertainty about being reimbursed for their cost of cast supplies. This leaves the physician in a revenue loss situation for providing evidence-based care for diabetic foot injury or ulceration. Additionally, when payers do not recognize the distinct TCC procedure after a debridement or graft application, physicians and facilities are receiving inappropriate payment for services provided. This has lead to low adoption of TCC in the physician office and hospital clinic environment.

It is imperative that payers exercise appropriate uniformity in coding and reimbursement for TCC. This will help clinicians provide evidence-based approached for the treatment of diabetic/neuropathic ulceration of the foot and Charcot neuroarthropathy with TCC, which have been proven to heal significantly more ulcers and to be cost effective.

*CPT is a registered trademark of the American Medical Association.

Peggy Dotson RN, BS, is President, Healthcare Reimbursement Strategy Consultant: Helping clients succeed with their reimbursement approach. Peggy can be contacted at peggy_dotson1@yahoo.com.