Orthopedic Coding Alert

Question: I surgically repaired a patient's intertrochanteric hip fracture (27244). The following week, the surrounding bone collapsed and the hardward displaced due to osteoporosis, so I inserted an intramedullary hip screw to repair the problem. Which code should I report for the second procedure?

Texas Subscriber

Answer: Because you originally used a plate and screws to repair the hip fracture, you correctly reported 27244 (Treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage) for the first surgery.
 
During the second surgery, however, you inserted an intramedullary hip screw, so you should report 27245 (... with intramedullary implant, with or without interlocking screws and/or cerclage) on the second date of service, appended with either modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) or -78 (Return to the operating room for a related procedure during the postoperative period).
 
Modifiers -58 and -78 tell the payer not to include the second surgery in the first procedure's global period. But many consultants disagree regarding which modifier is most appropriate in a situation like this. Although some argue that the underlying disease (osteoporosis) prevented the fracture from healing and therefore created the need for more extensive treatment (necessitating modifier -58), other coding experts recommend modifier -78, stating that the osteoporosis would not have manifested itself in that way if the patient didn't have a plate and screws in her hip.
 
In the absence of carrier direction, your practice should establish a policy regarding which modifier you believe is most applicable, with input from your physicians, coders and billing staff.