Health Insurance Coverage for Toe Fracture Treatments

excuse me?

Hello Director Shih: I would like to ask about a toe fracture where a steel pin is only inserted from the tip of the toe, without performing surgery at the fracture site.
Is this considered one of the items covered under the National Health Insurance for closed reduction? Or is it part of the open reduction coverage? Additionally, which item in the National Health Insurance payment standards does this fall under, and what is its name? Thank you for your assistance, and I wish you a Happy New Year!

sam, 30~39 year old female. Ask Date: 2005/01/27

Dr. Shi Guozheng reply Orthopedics

The surgical method involves closed reduction combined with the use of bone pins, which is a common approach for treating fractures of the fingers or toes.
This technique achieves similar results to open reduction, where the skin is incised to visualize the bone for realignment and then stabilized with bone pins.
However, it is technically more challenging and may sometimes require assistance from X-ray or fluoroscopy to perform.
The payment standard may refer to a similar procedure, such as 64036c open reduction for fracture of fingers and toes.

Reply Date: 2005/01/27

More Info

When it comes to understanding health insurance coverage for toe fracture treatments, particularly in the context of a procedure where a steel pin is inserted into the toe without an open surgical approach, there are several important factors to consider.

In the case of a toe fracture, the treatment can vary based on the severity and type of fracture. The procedure you described, where a steel pin is inserted through the front of the toe, is known as closed reduction with internal fixation. This method is commonly used for fractures that are not displaced or can be realigned without the need for a larger incision. The advantage of this technique is that it minimizes soft tissue damage and can lead to quicker recovery times.

In terms of health insurance coverage, particularly under the National Health Insurance (NHI) system, it is essential to determine whether the specific procedure falls under the categories of covered treatments. Generally, closed reduction and internal fixation for fractures, including those of the toes, are typically covered by health insurance plans, provided that they meet certain medical necessity criteria.

To ascertain whether your specific procedure qualifies for coverage, you would need to reference the NHI's medical payment standards. The relevant codes for procedures are often categorized based on the type of intervention performed. For example, the code for open reduction of fractures might differ from that of closed reduction. In your case, since the procedure involves inserting a pin without an open incision, it is likely categorized under closed reduction.

The specific payment standard you are looking for can usually be found in the NHI's official documentation or guidelines. It is advisable to consult with your healthcare provider or the hospital's billing department to get precise information regarding the coverage of your treatment. They can provide you with the exact code and description that corresponds to your procedure, ensuring that you understand what is covered under your health insurance plan.

Additionally, if there are any complications or if the fracture does not heal properly, further treatments may be required, which could also affect coverage. It is crucial to keep open communication with your healthcare provider regarding your treatment plan and any potential follow-up procedures.

In summary, while closed reduction with internal fixation for toe fractures is generally covered by health insurance, it is essential to verify the specific details with your healthcare provider and the NHI's payment standards. This will ensure that you are fully informed about your coverage and any potential out-of-pocket expenses you may incur. Always remember to ask for clarification on any medical billing codes and the rationale behind the treatment plan to ensure you receive the best possible care.

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