Orthopedic Coding Alert

Question: You said on page 14 of the February 1999 issue, regarding wrist and finger fractures, to append modifier -51 (multiple procedures) along with HCPCS modifiers F1-F4 (left hand, X digit) or F5-F9 (right hand, X digit). It has been my experience that if you use both modifiers Medicare will reject your claim.

Also at a recent coding seminar, we were advised that if you added the modifier -51 with digit modifiers, you are then asking for your second and third procedures to be targeted for reduction of payment. Is this true?

Denise Caldwell, Office Manager
The Paducah (KY) Orthepaedic Clinic

Answer: There is no straightforward solution to this coding dilemma. Whether to use modifier -51 and/or finger modifiers will vary by payers. For example, with Medicare, even if you do not apply the -51 modifier to the finger fractures, the carrier will likely reduce the claim. Commercial carriers may deny all but the primary procedure without some sort of modifier. Some prefer the digit modifiers. Others prefer one line entry with number of units performed (when procedures are identical). Still others prefer the -59 modifier. The only way to know for sure is to check with the carriers you deal with the most to find out their requirements.

However, sources agreed it seem redundant to use both finger and -51 modifier; after all, payers will reduce the reimbursement with either method.

The rationale is that reductions for multiple surgical procedures occur because multiple surgical fees include overlapping or duplicate servicesespecially the portions of the fee designated as pre-op and post-op. So, in this wrist and fingers case, the same pre-op and post-op care was performed with the fingers as with the wrist; therefore, the fee will be reduced. The usual reduction is 50 percent for the second through fifth procedures. More than five procedures are paid by report, meaning the documentation is submitted and the carrier determines payment.

Thats why its important for you to list the major (and highest-paying) procedure first to better ensure it will be paid at 100 percent.