Orthopedic Coding Alert

Question: A closed reduction with manipulation is performed on an outpatient basis, and then (for various reasons) within a day or so an open reduction with internal fixation is performed on the same patient. What is the proper billing procedure? Do we bill for the closed reduction and then bill for the open reduction with modifier -58 because of the global period? Will this also reduce the reimbursement, and by how much? Should we bill for the ORIF and a hospital admission?

Debbie Stiles
Tupelo, Miss.

Answer: This question illustrates the importance of the use of modifiers, says C.J. Wolf, MD, CPC, senior coding consultant with Intermountain Health Care in Salt Lake City. Both of the procedures you mention (closed reduction and open reduction) have a 90-day global period. Your question is phrased in such a way that it sounds as if closed and open reductions were performed on the same fracture and youll be using the same diagnosis code for each. If this is the case, you will need a modifier for any additional services that warrant payment because you will be in the global period for the 90 days after the initial closed reduction. Modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be appended to the open reduction code.

According to Appendix A in the CPT manual, modifier -58 is used when the physician needs to indicate that the procedure or service during the postoperative period was:

a) planned prospectively at the time of the original procedure (staged);
b) more extensive than the original procedure; or
c) for therapy following a diagnostic surgical
procedure.

The open reduction is therapy that is more extensive than the original procedure.

If the open reduction is unrelated to the original closed reduction (i.e., a different fracture and thus a different diagnosis code), then modifier -79 (unrelated procedure or service by the same physician during the postoperative period) should be used. Reduced payment associated with modifiers is payer specific. The code and modifier selected should always be based on correct coding principles and not on the potential for reimbursement. When physicians and coders choose codes based on what will get reimbursed instead of what was actually performed, they are walking on shaky ground and setting themselves up for serious compliance issues.