Patrick07
Contributor
My question is about Medicare's rule regarding fracture care and the -54/-55 modifiers.
On April 1st, the patient presented to the ED with a closed humeral fracture. The patient was subsequently admitted to inpatient status when they were found to have pneumonia. Regarding the fracture care, the ED physician treated the closed fracture and reported 23600-54 with the intention on turning over care to an orthopedic physician. The ED fracture care and inpatient admission occurred on April 1st.
The orthopedic physician, per our documentation, performed an inpatient consult on April 3rd. This was the first time in the medical record that this patient was seen by this physician for this condition. The coders at the facility where I work submitted 23600-55 for this service. Medicare has denied the claim for the 23600-55 filed by the orthopedic physician stating that the claim must show the date of surgery as the date of service. The link below states Medicare's position:
http://www.wpsmedicare.com/j8macpartb/resources/modifiers/modifier-55.shtm
Should we have filed a claim with 23600-55 that occurred two days after the ED physician relinquished care to the orthopedic physician or can we file a claim with an inpatient consult (suitably cross-walked to an appropriately leveled E&M initial inpatient visit code per Medicare's consult rules) as is supported by the documentation provided by the orthopedic physician? Any insight or guidance you might offer would be greatly appreciated.
On April 1st, the patient presented to the ED with a closed humeral fracture. The patient was subsequently admitted to inpatient status when they were found to have pneumonia. Regarding the fracture care, the ED physician treated the closed fracture and reported 23600-54 with the intention on turning over care to an orthopedic physician. The ED fracture care and inpatient admission occurred on April 1st.
The orthopedic physician, per our documentation, performed an inpatient consult on April 3rd. This was the first time in the medical record that this patient was seen by this physician for this condition. The coders at the facility where I work submitted 23600-55 for this service. Medicare has denied the claim for the 23600-55 filed by the orthopedic physician stating that the claim must show the date of surgery as the date of service. The link below states Medicare's position:
http://www.wpsmedicare.com/j8macpartb/resources/modifiers/modifier-55.shtm
Should we have filed a claim with 23600-55 that occurred two days after the ED physician relinquished care to the orthopedic physician or can we file a claim with an inpatient consult (suitably cross-walked to an appropriately leveled E&M initial inpatient visit code per Medicare's consult rules) as is supported by the documentation provided by the orthopedic physician? Any insight or guidance you might offer would be greatly appreciated.