Orthopedic Coding Alert

Understanding when to use modifiers -50, -51, -59, -79 and -99 is vital to correctly code for multiple traumas such as those resulting from a car accident.

These car accidents often result in multiple skeletal injuries, which an orthopedic surgeon (OS) treats in a single (emergency) operating room (OR) session. The coders challenge comes later, telling the complete story, but not telling it more than oncethus avoiding duplicate billing. A common, but fictional, scenario illustrates the path to coding solutions.

Scenario: A driver fell asleep at the wheel and overturned his car on an interstate highway. He sustained multiple skeletal injuries in the serious one-car accident. A neurosurgical team admitted the patient and called in a consulting OS. The OS assumed responsibility for the treatment of the skeletal injuries.

During the initial operating room session, the OS debrided and closed an open knee (right) laceration, did an open repair of a syndesmosis disruption on the right ankle and pinned a left calcaneus fracture. The OS also treated bilateral talar neck fractures with open reduction and internal fixation, and treated a fifth metatarsal fracture with intramedullary screw fixation and a left foot Lisfranc fracture dislocation with open reduction and pinning.

Six days later, the patient underwent an open repair (same OS) of a pelvic ring disruption (open reduction and internal fixation). The OS had not staged a repair of the pelvis during the first OR session.

The ICD and CPT codes that apply to the injuries are listed in the box on page 11. One reminder, however, is that this scenario also should be coded with the correct E (external causes) code from the ICD listings.

Coding: Here, the correct E code is E816.0 (motor vehicle traffic accident due to loss of control, without collision on the highway), which includes falling asleep at the wheel and overturning the car. E codes are never substitutes for primary diagnosis codes.

Modifier Questions

When coders look at this scenario, they are likely to ask two questions immediately. 1. Which is the appropriate modifier to use to code for the treatment of the bilateral talus fractures? 2. Which modifier applies to the repair of the pelvis, which was not staged during the first OR session?

Bilateral talus fractures: On first review of the treatment for bilateral talus fractures, some coders begin thinking about three modifiers. Modifiers -50 (bilateral procedure), -51(multiple procedures) and -59 (distinct procedural service) seem relevant.

In fact, at most, only two of the modifiers, -50 and
-51, are applicable. And whether both are used depends on the sort of payer the patient has.

Blair C. Filler, MD, FACS, director of medical education at Los Angeles Orthopaedic Hospital, explains. If this is a Medicare patient, only one code for the bilateral talus fractures should be submitted with a -50 modifier, says Filler. I would not add any other modifiers to this code since Medicare states (that coders are to) use a bilateral code only one time and to add a -50 modifier to one code. Medicare will then pay appropriately for both, and you have followed their rules.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., concurs with Filler. And she adds a few points she believes important to emphasize.

Most commercial insurance carriers have adopted the standard of reporting a bilateral procedure on one line, as defined by Medicare for years and by CPT since 1999. However, some still require that bilateral codes be listed on two lines with the -50 modifier added to the second code. Always check with your carrier before billing to get their specific instructions, says Callaway-Stradley. If using the one line method, the fee for the procedure should be increased to 150 percent of the base fee, since most insurance companies pay according to that formula. Also remember that to bill a bilateral procedure, the services on each side of the body must be identical.

What about the -59 modifier that attracts the attention of some coders? The -59 modifier is redundant and unnecessary in this case, says Callaway-Stradley. The
-59 modifier would be used only if the treatment of the bilateral talus fractures were bundled into something else performed on the same day. Then the physician must request the procedures be unbundled, if it is appropriate, by using the -59 modifier.

But that is not the case in this scenario. If such an instance arose, however, the -51 modifier would not be needed. If the -59 modifier is used, you do not need the
-51, says Callaway-Stradley.

Modifier -78 vs. -79

Repair of pelvic ring: A review of the scenario causes some coders to pause and think about the difference between modifiers -78 (return to the operating room for a related procedure during the postoperative period) and -79 (unrelated procedure or service by the same physician during the postoperative period). Has -78 any relevance here, or does modifier -79 describe the progression of events?

Filler and Callaway-Stradley agree that -79 is the appropriate choice for reporting the pelvic surgery that takes place six days later.

The -79 modifier means unrelated to the original surgery, explains Callaway-Stradley. And she points out that the physician did not treat the hip in any way during the first OR session. Thus, there is no question of it being unrelated.

Filler elaborates, Use -79 for the pelvic fracture fixation. The surgery had no relation to the other procedures performed on the first day. Whether it is a new or old injury makes no difference.

Modifier Coding Cautions

Modifier -78: Use the -78 only if the related procedure is related to what was done at the first surgery, says Filler. If the physician returns the patient to the operating room to treat a postoperative complication, says Callaway-Stradley, modifier -78 is used.

Note: For more on the distinction between modifier
-78 and modifier -79, see Modifiers -52, -53, -76, and
-78: Optimize Failed Procedure Reimbursements on page 49 of the July 1999 Orthopedic Coding Alert.

Modifier -58: There are cases where the -58 modifier (staged or related procedure or service by the same physician during the postoperative period) is the choice, instead of the -78. For example, if during the initial OR session, the OS staged the procedure for the hip, a -58 modifier would accurately describe the second session. Here, the return to the operating room occurs because the physicianfor whatever reasononly started (or staged) the procedure during the first session. There were no staged procedures in this scenario since a staged procedure would be one planned at the time of, or more extensive than, the original procedure but related to the original problem. The hip fracture was not related to the leg fractures.

Modifier -99: If multiple modifiers are needed for the same procedure code, reminds Filler, attach -99 (multiple modifiers) to the code, and on other lines on the billing form use the resulting five-digit descriptor instead of the modifier.

For example, if both -50 and -51 are used to report the treatment of bilateral talus fractures to a commercial payer, the -99 modifier is attached to basic procedure code. On the other lines on the billing form, the five-digit code instead of the modifier is used (i.e., 09951 [All five-digit modifiers begin with 099 and are followed by the appropriate modifier, in this case -51.]). Even though CPT says to use modifier -99 first, some carriers may allow processing of two modifiers at a time before requiring the -99 modifier. Always check with your carriers for specific requirements such as this.

Additional Reporting

The OS will report seven different CPT codes for this scenario, not an unusual occurrence when there is a multiple-trauma patient. But there is another important reminder from Filler. The physician submitting the billing in many cases will have to append a letter detailing the extensive surgery needed, says Filler. Only five procedures will automatically be eligible for the 50-percent reimbursement. If there are more, the rules require a report.

And because a neurosurgeon admitted the patient and the OS was at first called in to consult, the initial encounter the OS had with the patient can be billed as an initial inpatient consultation. In this scenario, 99255 (initial inpatient consultation for a new or established patient, which includes a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) is likely to apply. The range of the potentially applicable codes is 99251-99255. But the time the physician spends with the patient should be documented to bolster the choice.

Note: See the Reader Question in this issue, page 15, for more on the topic of consultation in a hospital setting.