Orthopedic Coding Alert

Just because you can't complete an orthopedic procedure doesn't mean you can't get paid for it. Modifier -52 (Reduced services) can help your practice gain reimbursement for procedures that comprise fewer services than the CPT code describes.

For instance, the orthopedist performs an arthroscopic subacromial bursectomy without acromioplasty. Although some practices might be tempted to report the unlisted-procedure code (29999, Unlisted procedure, arthroscopy), the more accurate choice is 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) with modifier -52 appended, says Ruth Hoham, MS, CPC, a coder at the Center for Bone and Joint Surgery in Port Angeles, Wash.

The reduced-services modifier is appropriate because the complete procedure as described in CPT was not carried out.

Use -52 for Closed,Then Open Reductions

Suppose a patient has a hip dislocation and reports to your orthopedic practice. The orthopedist attempts a closed reduction, hoping to forego surgery for the more conservative treatment. The closed reduction fails, however, and the patient requires an open reduction the next day by the same physician. Can the practice bill for both services?

The right to receive reimbursement for a procedure does not rely on its success or failure, so both attempts can be billed, says Donna Watkins, billing coordinator at Hiler Sports Medicine, a two-orthopedist practice outside of Washington, D.C. Because the closed treatment failed, the practice should bill 27250 (Closed treatment of hip dislocation, traumatic; without anesthesia) appended with modifier -52.

The next day, the practice would bill 27253 (Open treatment of hip dislocation, traumatic, without internal fixation) with modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) appended to indicate that the open procedure was related to the closed procedure but that the global period should be effectively "reset" because the closed reduction failed.

Use -52 for Unnecessary Procedure

Despite the extensive tests that orthopedists perform to ensure that surgery is necessary, sometimes they don't know exactly what's ailing the patient until they perform surgery. Occasionally, the surgeon will discover that the patient did not have the suspected condition and, therefore, abandons the surgery.

For instance, the orthopedist plans to remove a foreign body from the patient's knee but discovers upon opening that no foreign body exists. Consequently, he simply closes the patient in the operating room. This would warrant modifier -52 appended to 27372 (Removal of foreign body, deep, thigh region or knee area).

Don't Reduce Your Fee

Watkins recommends submitting claims for reduced services in hard-copy format rather than electronically: "This way, you can include information about how much of the procedure you were able to complete." Watkins advises coders to tell the insurer what percentage of the service the practice rendered to make it easier for the insurer to determine a reimbursement amount. "If you don't tell them the percentage of the fee you want, they'll determine it for you. And obviously they aren't going to always be right," Watkins says. "They may not follow your recommendation, but it should help them at least find a starting point."

Do not cut your fee when using modifier -52 because the insurer will cut it for you and you don't want the reduction taken more than once.