Orthopedic Coding Alert

Modifier -77 (Repeat procedure by another physician) is reported when another physician repeats a procedure on the same day. The modifier alerts the payer that you have not mistakenly reported the procedure twice.

In the orthopedic setting, repeat procedures are often relevant to x-rays and fracture care. Although rare, two physicians may perform the same procedure on a patient on the same day, and this is most likely to occur in an emergency room.

For example, a 45-year-old male factory worker slips and falls on the job, landing on his shoulder. He is taken to the emergency department (ED) where an x-ray of the shoulder (73030, Radiologic examination, shoulder; complete, minimum of two views) confirms acute dislocation (831.04, Dislocation of shoulder; closed acromioclav-icular), which the on-call orthopedist reduces (23650, Closed treatment of shoulder dislocation, with manipulation; without anesthesia).

The patient goes home and falls asleep on his couch after taking pain medication. He rolls off the couch reinjuring the shoulder. He returns to the ED, where another orthopedist from the on-call group orders new x-rays (73030), confirming the shoulder is again dislocated. He resets the shoulder (23650) and releases the patient in a shoulder sling with orders to rest his shoulder for several days.

The on-call orthopedist would report 23650-77 to indicate the repeat procedure. In this case, the x-ray code is not billed by the on-call orthopedist because the hospital's radiology department presumably handles both the technical and professional aspects.

Unfortunately, because the carrier will balk at paying two physicians for the same procedure performed on the same date of service, the first to submit billing is likely the one to get paid. The second surgeon will have to appeal a likely initial denial with documentation of the ED visit showing the medical necessity of the second reduction. Although using modifier -77 in theory should reduce the likelihood of this problem, you should anticipate it and be prepared to appeal.