Orthopedic Coding Alert

Proper coding for procedures performed on multiple fingers and toes is a challenge because there are as many different modifiers designating which digit is affected as there are fingers and toes. Familiarizing yourself with these modifiers, as well as with ways to bill for the same procedure on multiple digits, leads to correct coding and proper reimbursement.

Finger Codes

Part of the challenge of coding finger procedures is the staggering number of codes in the Hand and Fingers section (26000 series) of CPT 2002. The codes cover fasciotomies, tenotomies, synovectomies, repair or lengthening of tendons, fracture reduction, arthrodesis and amputation. Common injuries to the fingers are usually the result of trauma (crushing accidents, lacerations, falls) or repeated stress through occupational or recreational pursuits (such as trigger finger).

Many code descriptors for finger surgeries include the word each"" (e.g." 26535 Arthroplasty interphalangeal joint; each joint) indicating that the code is intended for surgery on one digit or joint only. Some code descriptors specify the number of digits per surgery (e.g. 26517 Capsulodesis metacarpophalangeal joint; two digits). Other code descriptors are not as specific (e.g. 26568 Osteoplasty lengthening metacarpal or phalanx).

Ensuring that the claim form accurately represents the surgeries performed means not only understanding these distinctions in code descriptors but also appending proper modifiers to each CPT code. Since most surgical procedures do not designate which digit is being repaired identifying the digit in question is essential. HCPCS Level II modifiers found on the inside front cover of CPT 2002 are appended to CPT codes for this purpose. Modifiers -FA and -F5 apply to the left and right thumbs respectively; -F1 -F2 -F3 and -F4 apply to digits on the left hand; -F6 -F7 -F8 and -F9 apply to digits on the right hand.

These modifiers signal to the carrier that multiple entries of the same code are not a duplication but rather that the same procedure was performed on different digits.

For single or multiple procedures of the fingers the appropriate modifier is chosen to indicate which finger was worked on.

For example the claim for a patient who has a crush injury to fingers of the right hand with open fracture of the middle phalanges and requires an open reduction of each fracture might read as follows:

816.13 (Fracture of one or more phalanges of hand; open; multiple sites)

26735-F6 (Open treatment of phalangeal shaft fracture proximal or middle phalanx finger or thumb with or without internal or external fixation each-Right hand second digit)

26735-F7 ( Right hand third digit)
26735-F8 ( Right hand fourth digit).

Billy Jo McCrary CPC CCS-P practice manager for Wellington Orthopaedic & Sports Medicine in Cincinnati offers another coding tip that has facilitated reimbursement for her practice.

"In addition to utilizing the digit modifiers we include a quick reference to 'Separate fingers' or 'Different toes' on the claim form." She says it reduces confusion at the carrier's end allowing for fast and efficient approval of the claim.

Although Medicare always requires HCPCS Level II modifiers in these cases you must take a different approach with carriers that reject these modifiers in favor of modifier -51 (Multiple procedures). Using modifier -51 and the HCPCS modifiers together on a claim (unless specified to do so by the carrier) is redundant and could result in the claim being denied.

With the finger modifiers pay particular attention to the code descriptor identifying the procedure that was performed.

For example none of the HCPCS Level II modifiers (-FA through -F9) need to be appended to 26518 (Capsulodesis metacarpophalangeal joint; three or four digits) because reimbursement for this procedure is already based on multiple fingers. The operative report however should indicate which fingers were repaired.

Note that billing for different procedures performed on different fingers could result in a carrier denying the claim on grounds that the procedures are bundled especially if the code descriptors either specify the number of digits that apply or omit reference to "each" digit.

For example a patient undergoes a tendon sheath incision (26055) to repair a trigger finger on the left thumb and excision of a ganglion cyst (26160) from the left middle finger.

The claim would probably be denied if it were coded as either 26055-FA and 26160-F2 or 26055 and 26160-51 because 26160 is bundled with 26055.

In this case you should bill 26055 and 26160 with modifier -59 (Distinct procedural service) appended to 26160. This tells any carrier that recognizes the 26055/26160 combination as bundled that the circumstances of the surgery justify unbundling the codes.

You should remember that regardless of the modifiers used reimbursement on subsequent procedures will be less than the full relative value units. The rationale is that since the surgeon only has to do the work of one pre- and postoperative period he or she should not get paid more than once for those services on the same patient in the same operative setting. Expect reimbursement on the second and subsequent procedures to be 50 percent or less.

Also remember that a well-written operative report helps in obtaining proper reimbursement.

The report should clearly indicate the preoperative diagnosis postoperative diagnosis and procedures that were performed.

Toe Codes

Modifier rules for toe surgeries are essentially the same as those for fingers: Modifiers -TA and -T5 apply to the left and right great toes respectively; -T1 -T2 -T3 and -T4 apply to digits on the left foot; -T6 -T7 -T8 and -T9 apply to digits on the right foot.

McCrary notes that hammertoe corrections (28285) are among the most common foot procedures and are usually performed on multiple sites.

When billing for multiple procedures on multiple digits or for the same procedure on multiple digits enter each digit on a separate line on the claim form rather than attaching multiple modifiers to the same code (e.g. 28285-T6 -T7 -T8).

If the CPT code descriptor already indicates a particular digit (e.g. 28505 Open treatment of fracture great toe phalanx or phalanges with or without internal or external fixation) the HCPCS Level II modifier need not be appended.

Research Carrier Policy on Modifier Use

There are carriers that only recognize a limited number of modifiers and many have lists specifying which they accept. The appropriate HCPCS Level II modifier will have no impact on claims processing if the carrier's system is not programmed to recognize it and respond appropriately to its use.

Stanley M. Szelazek CPC CCP certified orthopaedic proficient compliance officer at Lighthouse Orthopedic Associates in Lighthouse Point Fla. also points out that these modifiers often get rejected as duplicate billing.

Szelazek refers to the provider contract looking for specific verbiage regarding how to bill to receive payment for these services. "If I can identify a solution in the contract then I will comply with their guidelines " he says.

Failing that Szelazek contacts the provider representative for guidance on how to submit the claim.