Orthopedic Coding Alert

Question: A patient comes in for an x-ray and cast change during the 90-day global period. Is there a modifier that will pay for the cast change? [What about]
injections during the global period relating to primary procedures—what modifier can you use?

MA Subscriber

Answer: Annette Grady, CPC, CPC-H, coding and reimbursement coordinator at the Bone and Joint Center in Bismarck, ND, says if the "circumstances"—such as "ill-fitting cast, signs of drainage, broken cast"—are there, payment for a cast change should be made. You may need to append a modifier. The need for a modifier, and which modifier to use, must be verified with your carrier. The most likely modifier would be -79 (unrelated procedure or service during the postoperative period). The correct diagnosis code must also be linked to the service (such as V53.7, orthopedic cast; 707.0, pressure ulcer due to cast). Injections given during the postoperative period for reasons unrelated to the surgery would also require the use modifier -79.

The exception is if the change falls within the first 14 days of the life of the cast. Many carriers may deny a new cast during that interval, Grady notes.

Even then, however, the change offers the possibility for partial cost recovery. "You can charge for supplies, for different types of fiberglass, for example," explains Grady.

What’s wrong with using modifier -59 (distinct procedural service)? It is a bit ambiguous, Grady says. Technically, it should be used only to refer to procedures accomplished during the same 24-hour period.

Even when carriers recognize modifier -59, its use can trigger audits. It is best used as a last resort—i.e. no other modifier describes the situation.