June 10, 2021
Our physician diagnosed non-displaced middle phalangeal fractures on the right index, middle, ring, and little fingers on a high school student. The physician applied a short arm cast as treatment and wants to report CPT code 26720 four times. I explained to the physician that she may only report this code one time as a single cast was applied. She does not agree with me. Am I correct?
First, based on your description, CPT code 26720 (Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) is the correct code.
Both of you are correct depending on what rules are being applied.
The scenario describes middle phalangeal fractures on four separate fingers; note the term “each” in the CPT code description. If you are following CPT rules, the physician is correct to report 26720 for each of the fingers; KZA recommends reporting each code with the appropriate finger modifier; alternatively you could report the code with four units (the finger modifiers represents more specific coding and reporting).
This is a high school student and most likely does not have Medicare coverage unless the student is on disability.
Medicare NCCI Rules:
Medicare, via the National Correct Coding Initiative (NCCI) guidelines, instructs that multiple fractures in the same area treated with a single cast (example) may only be reported one time.
The following citation is found in Chapter IV (Musculoskeletal System) of the NCCI Policy Manual.
16. If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported.
CPT code 26720 is reported one time for the management of the four individual fractures if your practice applies CMS NICC rules to all patients, or if the payor contract states that NCCI guidelines are used.
*This response is based on the best information available as of 06/10/21.