ED Coding and Reimbursement Alert

& but certain patient situations might make modifier 54 unnecessary.

ED coders will append modifier 54 (Surgical care only) to nearly all procedure codes that include follow-up care. If your physician provides fracture care for a patient, for example, odds are he wont be seeing the patients recovery through to the end.

There are exceptions to this rule, however, and they can occur with any type of procedure requiring follow-up care, not just fractures.

Physician Must Fill Specialists Role

Lets say the ED physician uses manipulation to treat a patients closed humeral shaft fracture. He casts the arm and releases the patient to an orthopedist for follow-up.

On the claim, you must append modifier 54 to 24505 (Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction), confirmed Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network, and executive officer on the AAPCs National Advisory Board.

If you are not going to append modifier 54 to this claim, your ED must conduct a 90-day treatment plan consisting of restorative treatment or procedure; all postoperative visits; and initial application of cast or durable medical equipment device, Grady explained during a recent Coding Institute audioconference on orthopedic procedures (www.audioeducator.com).

Exceptions exist: There are certain situations in which the ED might provide definitive care for a patient.

If the ED is in a rural area with few specialists, a patient might return to the ED for more care. Or if a patient is without a primary care physician, he might also end up back at your ED for follow-up care

Example: The ED physician treats a patient with a closed fracture of the humerus of his right arm Because there are no orthopedists within 250 miles, the ED physician informs the patient hell need to come back in a week to start his follow-up and restorative care. The ED physician personally manages the entire episode of care over the 90-day period.

If the physician takes on this role, you can report the 24505 code without modifier 54.