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 of the procedure was actually completed.

There is no set percentage of the allowable fee; it depends on what the report shows, and how the payer calculates reimbursement for that portion of the procedure that was completed, explains Callaway-Stradley.

It may be 50 percent. It may be less or it may be more, says Callaway-Stradley. For example, the patient may have crashed in the last five minutes [of a lengthy procedure], so you would be entitled to more than if it happened immediately after the procedure began.

The crucial element, reminds Callaway-Stradley, is to append the appropriate modifier. When you attach modifier -53, the payer reviews the claim and operative report, looking specifically for dictation which supports or identifies the extenuating circumstances that threaten the well-being of the patient that required the procedure to be discontinued, she says. But if the documentation supports only that the procedure could not be completed, based on the CPT code description, then the payer will deny any payment for the claim as inappropriate use of modifier.

In that case, you would have to resubmit an amended claim, showing modifier -52, along with the report.

The insurance company will determine the reduced amount to be paid. Do not reduce your own fees. Otherwise, you may receive less than the reimbursement to which you are entitled, she advises.

Note: Dont confuse modifiers -52 and -53 with modifiers -73 (procedure discontinued prior to the administration of anesthesia) and -74 (procedure discontinued after administration of anesthesia). Both sets of modifiers are used to indicate discontinued procedures; however, modifiers -73 and -74 should only be used in ambulatory surgery centers (ASC), not physician practices.

Other Modifiers Can Also Help With Pay-up

In addition to -52 and -53, another set of modifiers will help you optimize reimbursement for failed orthopedic procedures: -76 (repeat procedure by same physician) and -78 (return to the operating room for a related procedure during the postoperative period). For example, failure to use modifier -78 may result in a denial of a subsequent surgery. If you dont use -76, payers may think youve billed the original procedure twice and deny the subsequent one.

Append modifier -76 when the orthopedist performs the same procedure at a different time. (To establish medical necessity, youll need to justify the second procedure. Be prepared to submit the operative report.)

Append -78 when the subsequent procedure is related tobut not the same asthe original procedure and it requires a trip to the operating room. (An operating room means exactly thata surgical, laser, or endoscopic suitenot the patients room, a minor treatment room, recovery room, or intensive care unit.)

Dont just use -78 for complications. There are other circumstances in which a related procedure would need to be performed during the postoperative period of the first surgical procedure performed.

Note: Be sure to append -78 to the related procedure (not to the original surgery).

Dont Confuse Modifier -79 with -78

Its easy to confuse these two modifiers (-78 and -79). Both unbundle the subsequent procedure from the global period of the first surgical procedure so it can be paid; however, using the wrong one can result in a longer global period for the primary procedure.

Heres why: When you append modifier -78, a new postoperative period does not begin with that related procedure. Therefore, another 90 days is not added to the global period. (Its a good idea to monitor this fact to make sure carriers are honoring it. For example, if a patient requires a return to surgery for a related problem 75 days after a surgery with a 90-day global period, there are 15 days left on the global period. The carrier should not be denying E/M services after those days have passed.)

But when you append -79, a new postoperative period begins. Dont give away E/M services when you dont have to, urges Callaway-Stradley.

So when do you use modifier -79? Suppose a patient had a total knee replacement, but during the 90-day global also suffered a wrist fracture. You would append -79 to the appropriate procedure code; for example, 25620-79 (open treatment of distal radial fracture [unrelated procedure]).

Coding Examples

Lets look at how you can select from among these modifiers to optimize reimbursement correctly:


Case 1:

A patient undergoes a total hip replacement (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement). During the global period, the prosthesis becomes dislocated when the patient overextends her leg. The patient returns to the orthopedist, who, on two subsequent days, attempts two closed reductions without success. Finally, on the third day, the orthopedist returns the patient to the operating room and performs a successful
open reduction.

Coding Advice: First, because the interpretation of modifier -78 is carrier-specific, check with your local carrier and ask two questions:

1. Will they pay for a related procedure performed in the office during the global period of the total hip joint? (Some may pay only for procedures that require a return to the operating room.)

2. Do they require the -78 modifier to be added to procedures done in the office? (Although the CPT code specifies return to surgery, some carriers prefer -78 to be used to designate an unrelated procedure, whether a return to surgery was necessary or not.)

If your carrier pays for all three days, bill as follows:

For the first day, bill 27265 (closed treatment of post-hip arthroplasty dislocation; without anesthesia). Append -52 (reduced services) because the orthopedist was not able to complete the procedure as described in the CPT. Append -78 if your carrier requires it.

For the second day, bill 27265-52, but also append -76 to show it was a repeat of the procedure done on the first day. Append -78 if your carrier requires it.

For the third day, bill 27266 (closed treatment of post-hip arthroplasty dislocation; requiring regional or general anesthesia). Append modifier -78 to show that the third procedure was related to the first and required a return to the operating room.

Therefore, coding should be as follows:

Day 1: 27265-52 (-78)
Day 2: 27265-52-76 (-78)
Day 3: 27266-78

Note: Sequencing is not relevant because each procedure was performed on a different date.

Case 2:

A patient undergoes a total hip replacement (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement). During the global period, the prosthesis becomes dislocated when the patient overextends her leg. The patient returns to the orthopedist, who does not perform a procedure in the office, but returns the patient to surgery for 27266 (closed treatment of post-hip arthroplasty dislocation, requiring regional or general anesthesia).

Coding Advice: According to Callaway-Stradley the correcting coding for this case should be 27266-78 with a diagnosis code of 996.4 (mechanical complication of internal orthopedic device, implant and graft).

However, one coder interviewed suggested billing for both the preoperative history and physical that occurred in the office prior to the surgery and the procedure in the hospital as follows:

99214, appended by modifier -24 (unrelated to previous surgery) and -57 (decision for surgery).

27266 (closed treatment of post-hip arthroplasty dislocation; requiring regional or general anesthesia) appended by modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

The rationale is that an office visit can be charged because the patient injured herself and caused a new problem. Therefore, the solution to fix it is unrelated to the original procedure. (Medicare will not pay for office visits due to complications in the global period, but private payers might.)

Also, by appending -79 instead of -78, the coder attaches another 90-day global period in which no E/M services can
be performed unless there is a significant, separately
identifiable service.

However, Callaway-Stradley disagrees, stating that merely overextending the leg and dislocating the prosthesis is not an injury, but rather a complication of the hip replacement. Moving the leg is not a trauma, she explains. In this case, its not a matter of what happened to make the prosthesis fail, but that a complication did occur.