Published 6/20/2024
AAOS was recently made aware of widespread denials for splinting and casting supplies (Q-codes) relating to fracture care in several states across the United States. This issue represents a huge amount of lost reimbursement. Specific payers include Medicare Advantage, Aetna, UHC, Anthem, and Cigna. The supply codes being denied are for Q-codes Q4005 (long arm cast supplies for an adult) through Q4048 (cast supplies for a pediatric short leg splint).
The denials appear to be caused by claims-processing software, which has been flagging Q-codes as non-reimbursable and pointing to a determination by the Centers for Medicare & Medicaid Services (CMS), citing that supplies are now included in the global procedure and are not separately payable per CMS. However, the CMS website maintains that fracture care codes may be reported in conjunction with the Healthcare Common Procedure Coding System (HCPCS) Q-codes and are reimbursable. Furthermore, there are no National Correct Coding Initiative (NCCI) code pair edits on the CMS website, indicating that the codes may indeed be reported together. The software may be utilizing its own proprietary claim edits that do not align with CPT guidelines or CMS NCCI edits.
AAOS continues to monitor this situation and address it directly with payers.
Please direct any related denials via email at coding@aaos.org.