# opinions needed



## dmaec (Aug 19, 2008)

ok fellow coders, what's your opinion on using the modifier .57 on an E/M level along with a fracture care code (not cast/splint application code).  
For example would you code:
99213.57
27508

with the above codes, I'd only code out the fracture treatment code (and a Q-code), no E/M unless there were other issues addressed above and beyond the fracture.

To me, the modifier .57 belongs on the E/M if a decision for surgery was made the day of/ day before the surgery.  To me, fracture treatment isn't "surgery" UNLESS they're taken into surgery, open repair, etc.  at which point, I'd have no problem coding the E/M with the .57 and of course the surgical procedures would also be coded.

I'm being told (now)that fracture care "IS" surgery, due to the 90 day global -even if it's closed without manipulation!

I'm having trouble accepting this.

all opinions welcomed! help me see this one way or the other! 

THANKS!


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## ljohns31 (Aug 19, 2008)

I would think 25 would be better, if the E/M was separate identifiable.  57 says E/M service that resulted in the intial decision to "perform" the surgery.  

Lynne Johnson, CPC


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## ruhood (Aug 19, 2008)

It is my understanding that the global days determine the modifier... -57 for 90 day global procedures, -25 for anything less.


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## mbort (Aug 19, 2008)

I would code it with the E/M visit with the 57 modifier (of course with supporting documentation) and the fracture code.  Fracture care is considered a surgical procedure just like an injection (20610) is.

Sorry, I know this is what you were hoping to hear.
Mary


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## Lisa Bledsoe (Aug 19, 2008)

dmaec said:


> ok fellow coders, what's your opinion on using the modifier .57 on an E/M level along with a fracture care code (not cast/splint application code).
> For example would you code:
> 99213.57
> 27508
> ...



Donna - I agree with your thinking.  If the patient is not taken to the OR for reduction it seems to me that the fracture care itself covers the decision and procedure.  Yes, fracture care codes are in the sugery section of CPT and carry 90 day global periods, but that in itself does not mean that an E/M and mod -57 is appropriate.  "Just my opinion..."


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## Nancy (Aug 20, 2008)

*fx care and -57 modifier*

We just went through this with our orthopaedics dept. and compliance dept.  It was determined, by our compliance dept. that if the physician diagnoses the fracture at the time of the visit, then perfomrs fx care, we would bill the E/M with modifier -57 and the fx care code (as long as both are properly documented).  If the patient comes to us for fx care but has already been diagnosed with a fx (like in the ER or by PCP), then we just bill the fx care.

The previous post was right about the -25 and -57.  If the global is 10 days or less, like with a nasal fracture, you use the -25.  Anything else gets the 
-57.


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## dmaec (Aug 20, 2008)

thanks everyone for your input.

ljohns31 - I'd agree with a 25 on the E/M "if" there was something done above and beyond normal for the fracture treatment.  (I still believe 57 means decision for "surgery", not decision for fracture care - unless they're brought to OR for treatment)

ruhood - yes, I know that for minor procedures we can add a 25 modifier to the E/M, again, "if" there's something significant separately identifiable done at the same time as the procedure. 

mbort - I know fracture codes are listed in the surgical section of the CPT book, but so is "unna boot application" (29580) or "trimming of nails (11719) and several other procedures that aren't sugical. They both have zero global, non surgical but listed under the surgery section.   I'd have no problem appending a 57 decision for surgery to an E/M, again, "if" there was a decision for surgery. (not a decision to put a cast on, fracture care).  I don't think just because the codes are listed in the "surgery" section they're considered surgery.  I wouldn't considier 20610 surgery - I would consider it a procedure (injection/removal).

Lisa - obviously, I agree with you! LOL... and I'm glad someone sees my point 

Nancy - thank you for responding especially!  Because this whole issue came up in our facility from an ortho area!  They were saying the same as what your post is.   However, I still don't see it.

Everything I've read about fracture treatment, fracture care, ... everything I've been taught has always been; if they're providing fracture care/treatment you code the global, never and E/M with it UNLESS they're doing something above and beyond the fracture treatment itself. Or, the provider can choose to bill and E/M and "cast application" code instead of the global, with a 25 modifier on the E/M- but that most don't do that if they're going to be providing the whole service (global).  Nowhere does it state that a decision to apply a cast, initial fracture care or cast application, that you'd apply a 57 decision for surgery modifier to the E/M.  For fracture treatment it's "normal protocol" to take an xray, determine if it's broke and what the best care would be.  If it's a cast with or without manipulation, it's a global fracture care code without and E/M because nothing above and beyond "normal" was done.  If it's, "oh, a cast can't be placed until we fix this in surgery", THEN - it's a decision for surgery on the E/M, and no fracture treatment code because the treatment will be done in surgery (and that will be coded separately)

I'm still looking for clarification on whether or not a decision to apply a cast  would be considered surgery.

thanks again everyone for responding!


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## dmaec (Aug 20, 2008)

hey guys - here's a couple sites I found - take a look if you get the time and let me know what you think: 
(here, I "SEE", decision for surgery)
http://www.aaos.org/news/aaosnow/jul08/managing2_f3.pdf

http://my.clevelandclinic.org/disorders/fractures/or_overview.aspx

the second one has a bit of reading - but it states it perfectly:
Treatment can include surgical or non-operative options. Non-operative treatment usually consists of a period of immobilization in a boot or cast, followed by some type of rehabilitation. Surgical treatment utilizes internal fixation devices, such as screws and plates to immobilize the bones until they heal together. Surgery also usually requires a period of immobilization in a boot or cast, followed by rehabilitation. Both treatment modalities are combined with a period of no weight-bearing with crutches or a walker, or protected weight-bearing as pain allows. Often, the decision on surgical vs. non-surgical treatment is based on the bones involved, the amount of displacement, as well as the age and activity level of the individual.

given the above, if the decision was made to do surgical intervention - then I'd be adding the 57 mod to an E/M.  If it's non-operative - I'd say it's a fracture treatment code as they apply. (POS and documentation supporting of course)  

Surgery, in short - is "invasive" and carries a risk of infection.  It can be minor or major - but nonetheless, it's invasive and carries risks of infection.

_{that's my ending opinion on my own posted matter}_ 

*thank you ALL for your input!*


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## mbort (Aug 20, 2008)

here is an excellent article that is very helpful from the AAOS as well.

http://www.aaos.org/news/aaosnow/jul08/managing2.asp


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## dmaec (Aug 20, 2008)

thanks mbort!  
I'm finding articles on both sides of the fence on this issue! I found that one also, and printed it out.  I think that's the site where I posted that first example of when they used the 57.

who ever said coding was black and white hey!?

anyway - I feel confident and comfortable in my decision to "not" be using the 57 modifier on an E/M at the same time as fracture treatment, although I see some do.  It appears either way isn't "right or wrong".  I've never used it yet, and the coders I've worked with for years (and some of them have been coding for 20plus years) haven't either. (in this type of scenario).  So, I'm thinking for me, I'll continue with how I've been doing it.


thanks again for your input, it's great to get others points of few!


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## mbort (Aug 20, 2008)

You are so right...no black and white in the coding world!!

Be sure to save all of this documenation/articles/examples to back you up.  I've actually been coding with the -57 modifier for many years and fortunately have never been dinged for it in any of the audits I've been through.  The outside auditors/compliance are the ones that like to ding for it because it is considered "undercoding" or lost revenue in their eyes.


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## dmaec (Aug 20, 2008)

mbort - that's good to know! I was wondering about how auditors would view the use.  
Could you clarify though, do you "always" code an E/M and modifier .57 with the fracture treatment?  Or is it only when/if there are other UNRELATED issues are going on that are being addressed?  Much like we would use a .25 on E/Ms the same day as minor UNRELATED procedures.

thanks!


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## mbort (Aug 20, 2008)

Providing the documentation supports an E/M (sometimes some of my guys are lazy and don't deserve it) yes, I almost "always" bill the e/m with the -57 and the fracture code.  The only carrier that I can think of off the top of my head that does not pay for it is Medicaid.  Other than that, we have no issues with getting paid.


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## FTessaBartels (Aug 21, 2008)

*Yes, 99213 with 57 modifier & fracture care*

Our compliance office agrees with Nancy's compliance office ... For those cases where fracture care is provdied in the clinic/office setting without a trip to the OR ... if the patient arrives with a complaint but *no* definite dx of fracture, and the physician is evaluating the patient and determining there is a fracture and then treating it, we code the appropriate level E/M with -57 modifier and the fracture care (which carries a 90-day global period).

If the patient has *already been diagnosed *with a fracture (by ER or perhaps PMD) and the ortho service is being asked to treat, we just code the fracture care. 

As always, documentation needs to support the services billed. 

F Tessa Bartels, CPC, CPC-E/M


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## dmaec (Aug 22, 2008)

FTessaBartels, thanks for the response! (I was wondering when you'd respond!)    I still don't see the logic in using .57 (though, I know, I know the "guidelines") lol... I'm researching this quite extensively now, it seems to be a matter of opinion as to whether or not an office visit gets charged with the initial fracture care.  Some view in much the same way as a lesion removal -if that's all they're having done, all they're having looked at and attention to, then that's all that's coded, no office visit - just the lesion removal code... they feel the same for fracture care, of course it hasn't been diagnosed until after xray, being looked at - but if it's the only thing being looked at, the only thing being determined and placing the initial cast and planning the followups - they tend to bill/code only the fracture treatment code, no office visit. In both instances the exam and procedures are inclusive to the care, they "have" to look at the lesion and decide how to take it off, just like they "have" to do an xray to determine the extent of the injury. (obviously, I lean towards their way of thinking & interpretation of the guidelines).    Most that I've found, will use .25 modifier on the E/M "IF" there is another issue addressed, something unrelated to the fracture care and treatment.  Some I've found will use the .57 modifier in those instances.  I've always used the .25 in the past, but only if there was something above and beyond the fracture treatment.  I do believe I'll start to use the .57 (even though I don't agree with it), because of the 90day global rule.  But, I'll only use it if there's something other than the fracture care and treatment going on with that visit.
_{that's my game plan at this time anyway!}_

thanks again to ALL for responding with your opinions, I REALLY appreciate it, it's been VERY helpful!


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