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Offloading: Total Contact Cast (Cast Supplies)

Offloading: Total Contact Cast (Cast Supplies)

Offloading: Total Contact Cast (Cast Supplies)


This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.


  • check debridement

The cost of supplies used in creating casts are not included in the payment amounts for the CPT codes for fracture management and for casts and splints. Thus, for settings in which CPT codes are used to pay for services that include the provision of a cast or splint, supplies maybe billed with separate CPCS codes. The work and practice expenses involved with the creation of the cast or splint are included in the payment for the code for that service.

Medicare: The application of the TCC and ITCC (29445) and their materials (Q codes) should be billing the local Medicare carrier and not the DME MAC.

For claims with dates of service on or after July 1, 2001, jurisdiction for processing claims for splints transferred from the DME MACs to the A/B MAC (B). The A/B MACs (B) have jurisdiction for processing claims for splints and casts, which includes codes for splints that may have previously been billed to the DME MACs. CMS manual https://f1000.com/work/item/4574515/resources/3589392/pdf 

Cast Used for Reduction of Fractures and Dislocations ( New Temporary Q Codes) (A8559)

Total Contact Cast

  • HCPCS of covered items:
    • Q4038 - Cast supplies, short leg cast, adult (11 years +), fiberglass 
    • Q4037 Cast supplies, short leg cast, adult (11 years +), plaster 
  • Coverage requirements:
  • Frequency of replacement allowed by Medicare:
    • Use of HCPCS is linked to use of CPT code 29445 : for this CPT code - More than 8-10 visits for evaluation, treatment, modification and caregiver education would not be considered reasonable and necessary without significant documentation Local Coverage Determination (LCD):  Outpatient Physical and Occupational Therapy Services (L34049)
    • the frequency of application of a total contact leg cast (essentially the billing of CPT 29445 and reimbursement of the code) is factor of medical necessity and standard of care. Generally, total contact casts are left in place for 7-14 days (or longer). 
  • Non-covered conditions:

  • Billing reminders:
    • Billable unit: for Medicare - for each use, bill 1 unit regardless of how many rolls. For other insurance carriers,  Non-Medicare payers may be billed with the number of units equal to the number of rolls of plaster or  fiberglass material used - check first
    • Unlike with 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’s 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. https://www.podiatrytoday.com/blogged/back-basics-how-ensure-effective-offloading-total-contact-casting
    • Q4038 - Cast supplies, short leg cast, adult (11 years +), fiberglass  This is the ONLY code is used (regardless of how many rolls of plaster and fiberglass, who made it or what else is included in the kit) to get reimbursed for the materials you use in a Total Contact Cast.  The reimbursement for this is $40.17 per unit. That means each use of Q4038, NOT how many rolls you use.
    • CPT code 29445 - Application of rigid total contact leg cast is reimbursed in a facility (Hospital based wound care center) at $107.13 If you apply one in an office setting, the reimbursement for 29445 is $138.30
    • For those who use APC codes (Hospital Outpatient Facility), then you would have your indentured hospital lackeys charge $208.88. Remember that the hospital codes include the supplies as well as other stuff hospitals get to mix in and get paid for.
    • So for those of you who play by the rules and apply a Total Contact Cast, you can expect to get reimbursed approximately:
    • $147.30 in a facility
    • $178.47 in an office setting
    • Only $208.88 in the Hospital Outpatient Facility.
    • Debridement: The National Comprehensive Coding Initiative (NCCI) lists CPT 29445 as a component code of the wound debridement codes (11042-11047). Because the TCC application code is a component (Group II) code of the ulcer debridement code, this would normally not permit additional payment for the TCC. However, the NCCI does allow for modifier 59 to bypass the payment edit.  CPT article:  If a wound debridement is performed (codes 11042-11047, 97597-97598), any primary or secondary dressing materials used to cover the wound would be included in the debridement and would not be separately reported. However, a TCC is not considered a wound dressing and is not included in the debridement procedure. Therefore, the cast application should be coded in addition to the code for the appropriate level of debridement, if performed. CPT Assistant Archives - Application of Contact Cast in Wound Care Center (Q & A) (September 2011) - findacode

HCPCS Modifiers 


DME The AFO policy on CAM boots in the use of patients with ulcerations is quite clear in stating that CAM boots when used primarily to off-load an ulceration should only be billed using HCPCS A9280 (non-covered CAM Boot). Many manufacturers, as part of the ITCC kit, also provide a proprietary CAM boot to be used as part of the TCC. Though a CAM boot may be dispensed to a patient wearing a cast, in these situations, the boot is technically functioning more as a cast protector (e.g., cast shoe) than as an immobilizing device. Hence, the boot, whether purchased as part of a TCC kit or separately, should not be billed to the DME MAC as anything but a cast shoe (L3260). With some TCCs, only the plantar bo ot is pre-fabricated, with the remainder of the boot constructed directly on the patient and through a complex set of fabrication steps, right in your office. This custom-fitted TCC (not custom-fabricated) is quite sophisticated with the intended use by a single unique patient. For Medicare patients, the custom-fitted boot should only be billed to the DME MAC. The DME MACs have stipulated that a custom CAM boot is to be described by the miscellaneous HCPCS code L2999. Thus, whether offthe-shelf or custom-fitted, the boot would share the same fate, with neither product being reimbursable.   https://f1000.com/work/item/4574497/resources/3589370/pdf


 29445 (application of rigid total contact leg cast) with casting codes Q4037 through Q4040.

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