Orthopedic Coding Alert

Some orthopedists are under the misconception that procedures shouldnt be billed for if they were unsuccessful or had to be abandoned. This misconception can cost your practice revenue to which you are rightfully entitled.

Suppose an orthopedist attempted two closed reductions of a dislocated hip before performing an open reduction in the operating room. Should these unsuccessful procedures be billed and, if so, how? asks John M. Russell, MD, an orthopedist in Palm Coast, FL.

The right to bill for a procedure is not contingent on its success or failure, assures Susan Callaway-Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, in Augusta, GA. You are entitled to bill for those attempts even though they didnt work, she says.

The key to optimizing reimbursement in the case of a failed procedure is to choose the appropriate modifiers. The selection of the correct modifier depends on why the physician could not complete the procedure, as well as how much of it he or she actually completed before stopping, she says. However, using the wrong modifier will result in claim denials because payers may ask for an operative report to determine why the procedure was stopped.

When to Use Modifier -53 vs. Modifier -52

If the orthopedist stops the procedure because it is endangering the welfare of the patient, append modifier -53 (discontinued procedure). But if he or she is not able to complete the procedure for other reasons, such as the anatomy of the patient, append modifier -52 (reduced services). Use a -52 for an incomplete procedure and a -53 for a canceled procedure, Callaway-Stradley explains.

The distinguishing difference between modifiers -52 and -53 is that -52 reflects it was the orthopedist who could not complete the procedure as it is outlined in the CPT, while -53 indicates the procedure was started but had to be stopped because the patient experienced unexpected responses, says the American Medical Association (AMA).

Note: When a patient changes his or her mind and cancels the procedure, you cant use modifier -52 or -53.

Operative Report Directly Affects Pay-up

You cant file an electronic claim for incomplete or canceled procedures because the Health Care Financing Administration (HCFA) guidelines require payers to manually review all claims with modifier -52 or -53.

Therefore, detailed, accurate operative report
documentation is extremely important when billing
services with these modifiers, as reimbursement is directly assigned based on the procedure documentation. The
payer calculates payment based on how much [...]