Orthopedic Coding Alert

Here’s how to properly use modifier SG.

Suppose you bill Medicare when your surgeon treats a hip dislocation (27256), performs a knee joint revision (27440, 27446) or applies a long leg cast (29345, 29355) in an ASC. Do you know when the “same-day global” rule applies? Do you know when to apply modifier SG or discontinued modifiers? 

Although CMS has tweaked ASC coding rules in the past, some have remained the same. The following five ASC tips can help you button up your ASC coding.

1. Remember the “Same-Day Global” Rule

Every procedure billed by the ASC has a “same-day” global period. This 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.

For instance, if 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 physician’s coder and the ASC’s coder should report the appropriate control-of-bleeding code appended with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) because the procedure occurred within the -same-day- global period for the ASC.

If, however, the physician returned the patient to the ASC the day after the initial surgery, the ASC coder would report the appropriate control-of-bleeding code with no modifier attached. For the ASC’s purposes, the initial surgery’s global period has expired, even though the surgery includes a 90-day global period for physician services. On the other hand, the orthopedic surgeon’s coder would report the bleeding-control code with modifier 78 appended because the physician’s services still follow the standard global rule.

Takeaway: The ASC coder should follow the “same-day” global rule, but the physician’s coder should follow standard global period rules from the fee schedule, experts say.

2. Properly Append Modifier SG

When the ASC coder bills Medicare for any service performed in the ASC, she must list modifier SG (Ambulatory surgical center [ASC] facility service) as the first modifier on the claim. And 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) on the left great toe and performs a hammertoe correction (28285) on the left fourth toe in the ASC. 

The ASC coder should report 28285-SG-T3 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 (Distinct procedural service).

The surgical coder will report 28292-TA as the primary code (due to 28292’s higher relative value), followed by 28285-T3-59.

3. Discontinued Coding Modifiers May Differ

ASC coders may occasionally use modifier 52 (Reduced services) but won’t use modifier 53 (Discontinued procedure). Instead, insurers usually require ASC coders to call on modifiers 73 (Discontinued outpatient hospital/Ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) or 74 (Discontinued outpatient hospital/Ambulatory surgery center [ASC] procedure after administration of anesthesia), as appropriate.

For example: A surgeon is treating a torn meniscus (29881, Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving] including debridement/shaving of articular cartilage [chondroplasty], same or separate compartment(s), when performed). But after the procedure has commenced, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the patient’s vital signs, the surgical team decides to discontinue the surgery. The surgical coder should report 29881-53, and the ASC coder should report 29881-SG-74.

Note: Medicare keeps the full list of allowable ASC procedures on its Web site, according to the year that the physician performed the service. Visit the CMS site www.cms.hhs.gov/ASCPayment/ for the full list of ASC-allowed procedures.