Podiatry Coding & Billing Alert

Apply this sequencing advice to ethically maximize reimbursement.

Not paying attention to work units for all the fractures that your surgeon is treating can turn these procedures into a cash sinkhole. The solution? Ensure you are paid the highest value code at the highest percent of payment and keep in mind that codes submitted beyond the first may then be reimbursed at half of their values. Follow our expert advice on sequencing.

Grasp Hierarchy Fundamentals

You’ll order your fracture codes using the RVU listing for the fracture codes. "The services should be listed in order of RVU hierarchy on the claim form to avoid potential issues under reimbursement. Improper ordering can lead to a multiple procedure discount on a higher valued procedure if the highest valued procedure is listed in the secondary position," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder and auditor with The Coding Network, Washington.

Be Sure to Confirm With Your Payer

 Since payer policies vary, check with your payer to verify sequencing. "In general we would try to report these based upon the RVU value for the fracture management; however, Medicare and many other but not all health plans state that they pay based upon RVU, not based upon order in which the codes appear on the claim," says Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A.

Example Shows You How

Example: If your podiatrist is treating closed fractures in the left talus and calcaneus and does manipulation to treat the calcaneus fracture, you report codes 28405 (Closed treatment of calcaneal fracture; with manipulation)-LT and 28430 (Closed treatment of talus fracture; without manipulation)-LT.

You list the RVUs for the codes for the calcaneus (28405) and talus (28430) fractures. Code 28405 is worth about $350.78 (10.31 transitioned facility RVUs multiplied by the 2013 Medicare conversion rate of 34.023). The 28430 code is worth about $215.71 (6.34 RVUs multiplied by 34.023).

Since the payer will pay a modifier 51-appended code (28430) at 50 percent its total value, you see that your payment for 28430 will reduce by half, i.e. $107.855. On the other hand, if you report the reverse order in the example above, i.e. you append modifier 51 to 23405, you are certain to lose much more on your payment. Your payment will now fall by half of the 28405 value, i.e. by about $175.39

So, the correct order of the claim will be 28405, 28430-51. This helps you to maximize payment.