Wiki Surgery in another state.

[LLRodgers]

Hello,

Can anyone advise how you code a surgery done in another state and they come home and being treated here for followup:

Patient fell while cutting branches out of tree, ended up having surgery (ORIF) for a right proximal humerus and humeral shaft fx in New York. She then returned home to Pennsylvania and we are following her treatment now.

I coded the fracture with a Z98.890 with a 99202 with a modifier 55. It is being denied.

Can anyone advise me how this should be coded.

Thank you,
LLR

 

[Orthocoderpgu]

You have a problem that you may not be able to fix

The doc in NY, knowing that they were not going to treat the patient during the post op period should have billed out the fracture code with a -54 modifier. I'll bet you anything that they did not. If they did not, they were paid the global procedure and you won't get paid no matter what you do. That's reality.

Your physician should only bill out the fracture code with the -55 modifier, but once again, unless the out of state doc used a -54 modifier on the fracture code your doc is not going to get paid.

 

[sxcoder1]

Modifier 55 is only used with a fracture CPT code, and only if the original ortho used modifer 54 which is probably unlikely. You can use 99202 without the modifer. You also need to use an S injury code for the fractures with the appropriate 7th character, which will probably be "D". You cannot use that Z code for an injury.

 

[MARY K]

why d on fx code? I thought if this is the first time treating for fracture a should be used no matter what previous tx was. I work in New York state and when this happens at our office bill by visit. Also have you thought about contacting other office to see what was billed exactly, I assume care was not taken over without records from treating physician in other state.

 

[sxcoder1]

7th character "A" means active treatment, not initial visit so the first time you see a patient might not necessarily be "A". A cast change can be considered "D".