Orthopedic Coding Alert

Heres why youll apply modifier 51 but forgo using modifier 59.

On a multi-traumatic injuries claim, you can obtain the highest ethical pay provided you follow this simple strategy: start with the most expensive procedure and work down, regardless of what your orthopedist performs first.

See if you can do it in the following scenario.

First, Read These Notes

A 21-year-old male who was struck by an automobile while riding his bicycle presents to the ED with a serious crush injury to the left lower extremity with massive swelling, ecchymosis, loss of sensation in the foot, and tightness of all four lower leg compartments and of the foot. He also complains of left elbow and shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left calcaneal fracture, left radial head fracture, and clavicle fracture.

The orthopedist admits the patient. The patient undergoes immediate surgery to stabilize his fracture and treat his acute compartment syndromes of the lower leg and foot. The surgery involves a closed reduction of the tibial plateau fracture with application of an external fixator. The orthopedist plans open treatment of this fracture and the calcaneal fracture once the patients fasciotomy wounds are closed.

Isolate Your CPT Codes

From reading the op note from above, you could determine that your orthopedist performed:

 " 27532 -- Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction
 " 2760x -- Decompression fasciotomy, leg; &
 " 28008 -- Fasciotomy, foot and/or toe
 " 20690 -- Application of a uniplane (pins or wires in one plane), unilateral, external fixation system.

You can also code for hospital admission with 9922x (Initial hospital care, per day, for the evaluation and management of a patient ...), says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, coding and compliance supervisor at Proliance Orthopedics and Sports Medicine in Bellevue, Wash.

Heads up: Remind your surgeons that you can report 20950 (Monitoring of interstitial fluid pressure [includes insertion of device, e.g., wick catheter technique, needle manometer technique] in detection of muscle compartment syndrome) if they perform and document this service.

Put Your Highest Money-Maker First

You should order the code with the highest relative value units (RVU) first.

Why: When your orthopedist performs several similar or related procedures at once, or when the circumstances of the injuries (for instance, a comminuted or crush fracture that requires more time and work) complicate a straightforward procedure, and you require modifiers, knowing the codes RVUs helps with your billing sequence. Because the insurer will discount the second and subsequent procedures, make sure you list the codes in RVU order, with the highest-paying code listed first.  You can find this information in the physicians fee schedule (http://www.cms.hhs.gov/pfslookup/).

The code with the highest relative unit will be the code for the closed treatment of the tibial fracture 27532-LT (Closed treatment of tibial fracture, proximal [plateau]; with or without manipulation, with skeletal traction; Left side), Stumpf says. You should apply modifier LT to better paint the picture of the claim. This code has 14.63 RVUs.

Sort Your Remaining CPT Codes by RVU

Next, report 20690-51-LT (Application of a uniplane [pins or wires in one plane], unilateral, external fixation system; multiple procedures) (13.74 RVUs). Some payers consider modifier 51 as an informational-only modifier and unnecessary, as the claim will show this is a multiple procedure claim, says Ruby OBrochta-Woodward, BSN, ASC-OR, coding and research specialist for Twin Cities Orthopedics, PA in Minneapolis, Minn.

After that, you should report the decompression leg fasciotomy code. Depending on the compartments released, you would report 27600 for anterior and lateral, 27601 for posterior only, or 27602 for anterior and/or lateral and posterior, OBrochta-Woodward says.

Youll most likely report 27602, because the scenario describes all four compartments as tight. This code has 13.38 RVUs. Depending on insurer, you might need modifier 51 on 27602. You can also apply modifier LT, Stumpf advises. For the fasciotomy, you should report 28008-51 (8.06 RVUs).

Rule Out Modifier 59 -- Heres Why

You could append modifier 51 to 20690, 2760x, and 28008 because your orthopedist performed these lesser-valued procedures during the same operative session. Modifier 59 (Distinct procedural service) is inappropriate for two reasons:

 1. Neither code has separate procedure designation.
 2. The combination isnt normally bundled.

Break the E/M Bundle With This Modifier
   
Finally, you should report 99222 (Initial hospital care, per day, for the evaluation and management of a patient ...) with modifier 57 (Decision for surgery). With the lowest RVU of any of that days codes, list 99222 last.

Modifier 57 reason: Payers would normally bundle 99222 into the global surgery package, but applying modifier 57 signals to the payer that the orthopedist made the decision for surgery at this encounter and should receive separate reimbursement.

Tally Your CPT Codes

Put these codes together, and you should have:

 " 27532-LT
 " 20690-51-LT
 " 2760x-51-LT
 " 28008-51
 " 99222-57.