The cast comes off in the same practice

Prior treatment

Synthetic record, September 9, 2026. An adult returns to the orthopedic practice that treated a closed left forearm fracture and applied the original cast. The earlier application is documented in this same practice’s record, and the practice continues the fracture follow-up.

Signed follow-up note

The treating clinician documents satisfactory interval healing and authorizes cast removal. A trained employee of the same practice removes the cast. This employee differs from the original applicator. Examination after removal shows intact skin, finger perfusion and sensation.

Care instructions

The clinician discusses gradual return to movement and follow-up precautions. No replacement cast, splint, cast repair or unrelated treatment is performed at this visit. The procedure record documents removal of the original device only.

Coding worksheet

A separate cast-removal procedure is proposed solely because a different staff member performed it. Apply Medicare NCCI’s entity rule. Review any E/M or other follow-up service under its own documentation and global-period rules; cast removal does not establish a separately payable visit.

Your coding worksheet

1. Identify the entity that applied and removed the cast.
2. Separate an employee change from an entity change.
3. Distinguish removal from replacement.
4. Apply the current removal inclusion without inventing another service.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.