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Casting, Strapping and Splints

Effective Date:
November 16, 2020

Purpose: To provide guidelines for processing claims for procedure codes 29000-29550, 29590-29799 (Casts, strapping and splints) when billed more than three times within a 90-day period.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, Medicare Advantage Plans, and SHBP are included.

Other ASO accounts will be included as an Opt-In option for additional claims editing on an account by account basis

Policy:
It is unusual to bill more than three casts, strapping and splints (29000-29550, 29590-29799) within 90 days. Three separate billings would cover the initial and 2 replacements within the global period. Therefore, codes 29000-29550, 29590-29799 (casts, strapping and splints) will be denied when billed more than three times within a 90-day period.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny 29000-29550, 29590-29799 (Casts, strapping and splints) when billed more than three times within a 90-day period.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions: While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

 

History:
06/22/2020: Policy Approved

Policy134_V1.0_06222020