Documentation Tips

Immobilization Care

Documentation Tips: Immobilization Care

Brault will only bill for custom / molded splints with either of the following types of documentation in the note:

  • Personal placement by the ED physician / MLP

— OR —

  • Placement by ancillary staff with a post-application check by the ED Physician / MLP

Note: Splinting/strapping may not be separately reported when included in Fracture Care, Reductions, Laceration Repair, Re-application of existing splint/strap, or when applied for comfort measures only.

Example of a well-documented splint application:

Procedure Note:

  • Hand injury treatment
  • Description: Injury type: contusion r/o salter fx, Location: left hand.
  • Confirmed correct: Patient, Procedure, Side.
  • Splint/strap: Location: left hand, Fiberglass, Immobilization placed by nurse, assessment by me was normal placement, circulation, motor, sensation.

Placement of Velcro splints, air splints or other pre-fabricated splints will not be reported.

If provider documentation does not meet the requirements to code, the coder will assign Deficiency Code 8182 which is tracked in the Downcode Report (supplied with practice Month-End Reports).

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