Orthopedic Coding Alert

Surgical care only? Use this modifier.

When your surgeon provides fracture care, there are opportunities for several separately codeable services. As the previous article in this issue proves, those opportunities can often depend on proper use of modifiers.

While the article “Remember to Code for All Services Surrounding Radial/Ulnar Fx” addressed many of the modifiers you could potentially need to fully code your fracture fix scenarios, there are still more that could come into play.

Check out this primer on some of the other modifiers that you might need during a fracture care encounter.

Surgical Care Only Requires This Modifier

Let’s say that your surgeon is only providing the preoperative and surgical care for the fracture patient — or even just the surgical care. This might occur if you’re treating a patient who lives in another area; or when the follow-up care is going to be handled by another physician, such as the patient’s primary care provider.

When this occurs, append modifier 54 (Surgical care only) to the fracture care code, confirms Yvonne Bouvier, CPC, CEDC, manager of coding documentation at ZOTEC Partners in Carmel, Indiana.

“Modifier 54 should be appended to the definitive fracture procedure when a provider is providing only the surgical aspect of the procedure: no postoperative care,” she explains.

Modifier 54 explained: “A coder should only append modifier 54 to the procedure code when an agreement has been made or when the performing physician is aware the patient will obtain preoperative and/or postoperative care elsewhere,” says Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, N.J. “With the 54 modifier, the rendering physician has only performed the intraoperative portion and expected reimbursement should roughly be 70 percent of the allowed RVUs [relative value units].”

Example: The surgeon meets a 3-year-old in the emergency department (ED); the patient has an obviously displaced right elbow. The surgeon performs an ED E/M that includes moderate medical decision making (MDM). They also order a two-view elbow X-ray, which shows a displaced radial head subluxation. The surgeon reduces the dislocation upon first attempt. Instructions are given to the patient to follow up with their primary care provider.

On this claim, you’ll report:

• 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) for the fracture care
• Modifier 54 appended to 24640 to show that you are coding for fracture care only
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the ED E/M
• Modifier 57 (Decision for surgery) appended to 99284 to show that the ED E/M led to the surgery
• 73070 (Radiologic examination, elbow; 2 views) for the X-ray
• Modifier 26 (Professional component) appended to 73070 to show that you are only coding for your surgeon’s services, not the use of the facility’s X-ray equipment

Warning: Because the X-ray was performed in a hospital setting, the orthopedist may not be able to bill for the interpretation (73070-26). Many hospitals have staff radiologists who are tasked with performing the interpretation of radiologic procedures performed in the facility. If you have any doubt about coding X-rays — or other imaging studies — in the facility, make sure you’re allowed to report them before including them on the claim.

Multiple Fractures? Modifier Could Vary

When your surgeon treats multiple fractures in the same patient during the same session, you will need help from either modifier 51 (Multiple procedures) or 59 (Distinct procedural service).

Making that choice will be entirely dependent on the situation, say experts.