Orthopedic Coding Alert

Remember, some modifiers are for E/Ms; others are for procedures.

Orthopedic offices see their share of fracture care patients. Often, coding for these patients is easy; the provider performs the fracture fix, sends the patient home, and puts the claim in the "To be filed" pile.

What happens, however, when you've got to include a modifier to get that claim just right? If you forget to append a modifier when it's necessary, your fracture care encounters could shatter your coding confidence and break off part of your bottom line with denials.

Not to worry: We've got the straight dope on how to use a pair of modifiers you might find yourself using when coding for fracture care encounters. Check out this expert advice on how to break the fracture modifier riddle and submit the correct codes for fracture care every time.

Use 54 for Surgical Care Only

One of the modifiers you might use for fracture care services is 54 (Surgical care only). Use this modifier most often when "the performing physician is aware the patient will obtain preoperative and/or postoperative care elsewhere," explains Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, N.J.

Remember that modifier 54 is for use on procedure codes, not evaluation and management (E/M) codes. A good way to remember this is to append 54 to the "definitive fracture procedure when a provider is providing only the surgical aspect of the procedure," confirms Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC, in Indianapolis.

Often, 54 is in heavier use around vacation hotspots, when people sustain fractures while away from home. When this occurs, a local orthopedic surgeon will often perform the fracture care, but turn the postop care over to a provider closer to the patient's home. Rogers paints a picture of proper modifier 54 use below:

Example: John, a 45-year-old patient from North Carolina, suffers a significant right ankle injury while skiing in Wyoming. The orthopedist diagnoses a right bimalleolar ankle fracture and surgically stabilizes the injury with open treatment and internal fixation. Notes indicate that the surgeon will turn over all postop care to an orthopedist in North Carolina, as John will only be in Wyoming for three more days.

On the claim, you'd report 27814 (Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed) for the ankle procedure with modifier 54 appended to show that the patient will receive postop treatment from another provider. Depending on the payer, you might also append modifier RT (Right side) to 27814 to indicate that the right ankle needed treatment.

Payout: "With the 54 modifier, the rendering physician only performs the intraoperative portion, and expected reimbursement should roughly be 70 percent of the allowed RVUs [relative value units]," says Rogers.

E/M Leading to Surgery Warrants 57

When the provider performs an E/M service for a patient that leads to surgery that day (or in the near future), you should append modifier 57 (Decision for surgery) to the E/M code, relays Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

The 57 modifier separates patient E/M encounters from major procedures (those with 90-day global periods), Rogers explains. You'll often use 57 during the patient's initial visit for an injury; however, you can use the modifier on an E/M "at any time during a patient's care, if the decision for major surgery is made the day of or day before the procedure," says Rogers.

Impact: Misuse of modifier 57 will lead to E/M denials, as payers will likely consider many preoperative E/M services part of the surgical package, Rogers warns. "This modifier tells the insurance company that a full review was performed in order to accurately assess the decision for surgery. Without the 57 modifier, the patient's visit would be considered preoperative and bundled into the procedure RVUs," she continues.

Consider these examples from Rogers, which also involve John the unfortunate skier:

Example 1: John fractures his right ankle while skiing near his home. He presents to his local orthopedist as a new patient, and the provider performs a level-four E/M service to fully assess the extent of John's injury, swelling, stability, and to perform x-ray review. Based on those findings, the orthopedist diagnoses a right bimalleolar ankle fracture and surgically stabilizes the injury using open treatment.

Since the orthopedist had to perform an extensive E/M in advance of a major procedure, you can report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) with modifier 57 appended in addition to 27814.

Example 2: John fractured his right ankle skiing eight months ago, and his local orthopedist fixed the fracture with implants. John's ankle healed well, but the implants are now causing discomfort and he wants them removed.

During the visit, the orthopedist performs a level-two E/M to review x-rays and discuss options with John. After this E/M service concludes, the orthopedist makes the decision to remove the implants the next day.

For this claim, you would report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) with modifier 57 appended to show that the orthopedist made the decision to remove the implants during the E/M.

Remember: The 57 modifier is only for E/Ms preceding major procedures. The implant removal that follows the 99212 encounter must have a 90-day global period. If the global is less than 90 days for the implant removal, choose another coding strategy; you shouldn't use modifier 57 on the E/M in this case.