Pediatric Coding Alert

Putting modifier 55 on fracture care codes can be your path to payment, provided the ED/clinic coder codes for her portion with modifier 54.

Here's how to get that to happen.

Appeal ammo: Your office should request a "referral for follow-up note" from the ED, recommends Donna Christianson, CPC, outpatient physician coder at Bigfork Valley Clinics & Hospital in Minnesota. In the event of a denial, you can submit the note showing that the ED/clinic provided only the surgical care (modifier 54) and the primary care physician (PCP) did the follow-up (modifier 55).

Preventive strike: With manipulative care, EDs/clinics are incorrectly using fracture treatment codes if they are not doing the follow up and not billing with 54, says Lynn M. Anderanin, CPC, CPC-I, senior coding consultant for Health Info Services in Park Ridge, Ill. "The pediatrician needs to discuss these issues with the EDs/clinics to determine how they can share fracture care if that is what they are going to do."

If the ED/clinic policy is to provide only initial surgical care to the patients, and to always refer the patient to a PCP for follow-up, "the EDs/clinics should hard code the modifier 54 to their procedure codes so that the PCPs can code their services without causing issue," Christianson adds.