Orthopedic Coding Alert

1 modifier makes all the difference - if you know when to use it correctly Treating infants can be especially challenging, and CPT offers a modifier -- modifier 63 -- to help you gain additional reimbursement for your orthopedist's efforts. But payment with 63 is not automatic. You can use the modifier only under very specific circumstances, and you-ll probably have to be extra vigilant with your documentation to support it. Consider Patient Weight You should append modifier 63 (Procedure performed on infants) only when the patient weighs less than 4 kg at the time of the procedure. "For those less familiar with metric, that 4 kg converts to approximately 8 lbs., 12 oz.," says Marvel J. Hammer, RN, CPC, CCS-P, of MJH Consulting in Denver. Applying modifier 63 indicates increased complexity and physician work commonly associated with neonates and infants of less than 4 kg, according to CPT Appendix A ("Modifiers"). More specifically, "In this population of patients, there is a significant increase in work intensity, specifically related to temperature control, obtaining IV access (which may require upwards of 45 minutes) and the operation itself, which is technically more difficult, especially with regard to maintenance of homeostasis," explains the AMA's CPT 2003 Changes: An Insider's Guide. Bottom line: The limit to append modifier 63 is 4 kg. If the infant weighs 4 kg or more, you should not append modifier 63, regardless of the patient's age. Append 63 to Surgical Codes Only You should append modifier 63 only to procedures and services listed in the 20000-69990 code series, according to CPT guidelines. What not to do: You should not append modifier 63 to E/M, anesthesia, radiology, pathology/laboratory or medicine codes. Example: A fracture of a newborn's clavicle can occur during a difficult vaginal delivery, Hammer says, and there is generally decreased arm movement on the side with the fracture. Generally, there is no treatment other than lifting the child gently to prevent discomfort. But if a pediatric orthopedist needs to immobilize the affected extremity on a newborn, he may append modifier 63 to indicate the greater work involved in treating the fracture (for instance, 23500, Closed treatment of clavicular fracture; without manipulation), Hammer says. If your orthopedist treats other neonatal conditions, such as 756.51 (Osteogenesis imperfecta), you may need to append modifier 63 to the orthopedic treatment/procedure codes if performed on small infants (weighing less than 4 kg), Hammer adds. Document Circumstances, Ask for Reimbursement When you apply modifier 63, the documentation must substantiate that the patient weighed less than 4 kg when the orthopedist performed the procedure. Because modifier 63 indicates an increased level of difficulty over and above that usually encountered, as well as risk to the [...]