Billing Solutions for Failed Closed Procedures
Published on Sun Oct 01, 2000
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 [...]
