Part B Insider (Multispecialty) Coding Alert

Document that the physician discussed risks the first time

When you're providing global fracture care, the patient sometimes may require extra treatment that goes beyond what's covered in the global period.
 
There's some controversy over what to do when the physician performs a closed reduction of a fracture, then two weeks later, the fracture slips and the physician must perform an open reduction of the same fracture.

In that circumstance, many coders advocate the -78 modifier (Return to the operating room for a related procedure during the post-operative period). But others point to the -58 modifier (Staged or related procedure or service by the same physician during the postoperative period).

Consultant Annette Grady with Eide Bailly in Bismarck, ND recommends using the -58 modifier, because when the physician performed the closed reduction, he should have mentioned the possibility of having to perform an open reduction later. The physician will say something like, "We're going to do a closed reduction and put you in a cast. Come back in two weeks and see how you do." And the physician will add that he or she may have to do an open procedure if the patient comes back with a problem.

Alameda, CA podiatrist Anthony Poggio also advocates using the -58 modifier. "You tried doing a closed first and then you go back and do the open." This is a common scenario, he notes.

One key point is that the closed reduction probably didn't happen in the operating room, notes consultant Cindy Parman with Powder Springs, GA-based Coding Strategies. "The closed reduction could be done anywhere," including in the office. But the wording of the -78 modifier (Return to the operating room) implies that the physician has already been there. "Based on that description, I would think the -58 would be more appropriate," she says.

It's key for "physicians to state in their documentation, 'I discussed with the patient that it may not hold. He may require a more extensive procedure down the line,'" Grady notes. Otherwise, they'll have a hard time making the case to the carriers that the later open reduction was part of a staged procedure with the closed reduction.