Orthopedic Coding Alert

3 ways your physician claim better look different than a center claim.

Think the same post-op and incomplete procedure modifiers apply regardless of whether youre coding for an ambulatory surgery center (ASC) or a physician? Save your claim from disaster by focusing on these variations.

Change Postoperative Surgery Coding After Day 1

Every procedure billed by the ASC has a same-day global period, which makes sense because the ASC is not reporting physician work services -- only facility fees.

This applies to the coder working for the ASC, but not the physician who performed the service, says Catherine Bowie, CPC, surgical and ASC coder for Central Maine Orthopaedics, PA in Auburn.

Example: A patient experiences postoperative bleeding and the physician must return the patient to the ASC for control of bleeding on the same day. Both the physicians coder and the ASCs coder should report the appropriate control-of-bleeding code appended with modifier 78 (Unplanned return to the operating /procedure room by the same physician ...) because the procedure occurred within the ASCs same-day global period.

Red flag: For postoperative operations beyond day 1, realize who you code for makes a difference in your modifier coding. The ASC coder should follow the sameday global rule, but the physicians coder should follow standard global period rules from the fee schedule, says Annette Grady, COSC, CPC-H, CPC-P, CCS-P, PCS, FCS, senior orthopedic coder and compliance auditor for The Coding Network.

Example: Suppose in the above example the physician returned the patient to the ASC the day after the initial surgery. Heres how the coding would vary:

The ASC coder should report the appropriate controlof-bleeding code with no modifier attached. For the ASCs purposes, the initial surgerys global period has expired.

The physicians services still follow the standard global rule.

The orthopedic surgeons coder would report the bleeding-control code with modifier 78 appended because the surgery includes a 90-day global period for physician services.

Consider Modifier SG on Non-Medicare ASC Claims

If you code for an ASC and youre billing a non-Medicare payer for any service performed in the ASC, you may need to append modifier SG (ASC facility service). If your payer requires it, remember to append modifier SG to every code listed on the claim, not just the first code.

For example, the surgeon performs a modified McBride bunionectomy (28292, Correction, hallux valgus [bunion], with or without sesamoidectomy; Keller,McBride, or Mayo type procedure) on the left great toe and performs a hammertoe correction (28285, Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]) on the left fourth toe in the ASC. The patient is a non-Medicare patient.

You should report 28285-SG-T3 (Left foot, fourth digit) as the first procedure (because the hammertoe correction is an ASC grouper of 3, which pays more),and the bunionectomy second (with a grouper of 2) as 28292-SG-TA-59 (Left foot, great toe; distinct procedural service).

Easier way: If you were reporting the above example for a Medicare beneficiary, you would not need modifier SG. Medicare no longer requires you to report this modifier, Bowie points out.

If you report on the physicians side, for this example, you would report 28292-TA as the primary code (due to 28292s higher relative value), followed by 28285-T3-59.

Take ASC Discontinued Coding One Step Farther

If youre coding for an ASC, expect a slightly different incomplete procedure modifier repertoire than a physician coder uses. In an ASC, you may occasionally use modifier 52 (Reduced services) but you wont use modifier 53 (Discontinued procedure).

Instead, ASC coders have to make an additional distinction that physician coders dont have to make.

insurers usually require ASC coders to call on modifiers 73 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to administration of anesthesia) or 74 (Discontinued ... [ASC] procedure after administration of anesthesia). Choose the correct modifier based on whether the surgeon discontinued the procedure before or after the patient was put under.

Example: A surgeon is treating a torn meniscus (29881, Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]). But after the procedure has commenced, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the patients vital signs, the surgical team decides to discontinue the surgery.

The surgical coder had to look only at one incomplete modifier option. The physician coder should report 29881-53. The coder has to also pay attention to the encounters anesthesias status. The coder should report 29881-SG-74.