Orthopedic Coding Alert

Question: How do I bill for an attempted ORIF (open reduction internal fixation) of an open comminuted articular fracture of the DIP (distal interphalangeal joint) with vascular compromise that was abandoned and an amputation performed?

Anonymous MN Subscriber

Answer: If the orthopedist spent an inordinate amount of time trying to reattach the finger before amputating, try appending a modifier -22 (unusual procedural services). Be sure to attach a summary letter stating in three or four sentences, in laymens terms, why the procedure was more difficult than usual and that an ORIF was first attempted. Conclude by asking for an additional 20 percent to 30 percent increase of the usual fee for an amputation.

Although it may seem appropriate, you would not use modifier -58 (staged procedure). This is because it indicates the steps were performed in a series of sessions. You also cannot bill for the ORIF with a modifier -52 (reduced services), because the CPT guidelines state that when a physician makes a switch midstream to another procedure in the same session, the more comprehensive procedure must be billed (i.e., the amputation).

Remember to include an operative report, because good documentation in such unusual cases is essential. Explaining what, when, and why each step was done could mean the difference in optimum reimbursement and a denial.