Orthopedic Coding Alert

CPT and carrier rules will not let orthopedists bill for an open procedure that is the result of a failed closed procedure. But there are ethical ways for orthopedists to get reimbursement for the extra work, time and expertise involved.

When an orthopedic surgeon is called to the emergency department to treat a common injury, like a dislocated shoulder (e.g., 831.00, closed dislocation of shoulder, unspecified), the anticipation is that the injury most likely will require a closed treatment (23655, closed treatment of shoulder dislocation, with manipulation; requiring anesthesia). But if the physician cannot satisfactorily relocate the shoulder through a closed method, he has to convert to an open procedure, such as 23660 (open treatment of acute shoulder dislocation).

No Billing for the Failed Procedure

Per the American Academy of Orthopedic Surgerys (AAOS) Complete Global Services Data for Orthopaedic Surgery, 23655 is bundled into 23660. (This resource is available from AAOS at (800) 626-6726 or by e-mail to custserv@aaos.org.) So when the surgery converts to the open treatment (23660), this precludes the surgeon from billing for the unsuccessful closed treatment. The Medicare Carriers Manual, section 4630, outlines corroborating rules on closed to open procedures. According to Medicares rules, failed procedures are deemed medically unnecessary and, therefore, not payable:

On occasions where it is necessary that the same provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported. Generally, this occurs when a less extensive procedure fails and a more extensive procedure is required. Failed procedures (and therefore medically unnecessary procedures) followed by a more extensive procedure should not be separately billed.

Use Modifier -22

Because there is considerable evidence both in writing and in carrier rejections that billing for the failed procedure is not successful, how best to maximize reimbursement? The closed procedure that switches to open in the same operative setting entails more work and time on the part of the surgeon, and merely billing for the 23660 alone does not adequately represent or reimburse for the work done in the operating room (OR).

Modifier -22 (unusual procedural services) should be appended to the code for the open reduction. Cathy Klein, LPN, CPC, senior consultant at Health Care Economics Inc., a coding and reimbursement consulting firm in Indianapolis, says that modifier -22 is the only real option for upping ethical reimbursement. I would append the -22 modifier to the open code and submit additional explanation in the form of a letter from the physician, as well as the operative note, she says. Klein explains that ideally, the operative note will explain in detail the extent of the complicated surgery and document the time spent in the procedures.

Joan Shurbet, RN, ONC, manager of surgical consultative services at the Christie Clinic, a multispecialty facility in Champagne, Ill., agrees with Klein. The -22 modifier appears to be the only way to increase payment on the open reduction and signal to the payer that extra work was done. The extra documentation you submit will help the payer understand the amount of time your physician spent in surgery.

Increase the Fee for the Open Procedure

Because there is no possibility of getting paid for the closed procedure, coders recommend that when appending the -22 modifier to the open procedure, orthopedic billers should increase the fee as well. I would increase the fee by about 25 to 50 percent, says Klein. The op note should provide the evidence to justify this increase. If it doesnt contain the detail you need to prove your case (for higher reimbursement), it should, and the physician will know next time to add more documentation to avoid denial of future claims. The amount that the fee is increased should be determined in discussions with the physician and can be based on the fee for 23655 (i.e., add all or part of the charge for 23655 to the fee for the open procedure), which will be significantly lower than the fee for 23660.

Staged Procedures

Shurbet says that in her practice, it is more common for a failed procedure to be deemed so after the initial surgery, and the patient has to return to the OR for the open procedure at a later date. We might see this with a closed reduction of a fractured wrist (25605, closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; with manipulation), says Shurbet. The doctor might attempt the closed procedure first and wait a week to see if it works. When the patient returns for x-rays and the closed reduction is revealed to have failed, the patient returns to the OR for an open treatment. At that point, we would pin the wrist to make sure the repair holds, she adds. Using 25620 (open treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid, with or without internal or external fixation), Shurbet bills with the -58 modifier for a staged procedure. We do this when the possibility exists of a return to the OR.

Use of modifier -58 acknowledges to the carrier that although this surgery is taking place within a global period, it is a separate procedure that is more extensive than the original and should not be reduced in payment. Because the original procedure was not determined unsuccessful until after the surgery, it is still appropriate to bill for both. But anticipate that some carriers will reduce either the original or the second, staged procedure, the concept being that they will not pay twice for global care.