Coding Center

Coding for the treatment of closed fractures is sometimes confusing. Hopefully, we can simplify this for you and provide the rationale for the coding. Closed treatment is either with or without manipulation and it is appropriate to list an E&M service with the fracture charge. A 25 modifier is listed with the E&M service. The exact E&M code is dependent on the level of service and the location. We want to review the two options the surgeon has for coding the fracture care. We can use global billing with a 90 days global or episodic/ itemized billing with no global. The American Academy of Orthpaedic Surgeons (AAOS) believes it is imperative that the treating surgeon have the latitude to choose the most appropriate option. There are often several variables such as co-pays, insurer policies and the amount of time and effort required to provide care that are important in your decision regarding billing options. The benefits of global billing include fewer claims/dates of service to adjudicate and cheaper/less administrative/staff processing. However, episodic billing is more appropriate for fractures that are minimal, require minimal follow-up or require a minimum of your expertise. So feel safe coding fractures as per contract instruction or by either the global or episode method.

In the next several coding corners we will address the correct use of modifiers. Let us set the ground work with definitions and the why/who/when (s) of modifiers. Modifier Definition – "…indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code." AMA Physicians’ Current Procedural Terminology – Richard J. Freidman, MD, presentation at the "Coding and Reimbursement Update 2008" Chicago, IL.

Why modifiers are used to : 1) Clarify services reported when they vary from the normal service descriptor; 2) Protect your correct reimbursement; 3) Prevent delays in payment; and 4) Prevent denials and costly/timely resubmissions and appeals.

When modifiers are used to: 1) Separate professional and technical components; 2) Service provided by more than one physician; 3) Service had increased or decreased level of service; 4) Indicate an adjunctive service; and 4) Indicate a bilateral procedure.

When modifiers are also used for: 1) Multiple procedure or same procedure performed more than once; 2) Service(s)/procedure provided within the global services period of another service/procedure; 3) Indicate occurrence of unusual events. Use modifiers "pro-actively" and make them a part of your coding regimen. Modifiers are used for any and all health care providers.

Modifier formats are: 1) a two digit appendage to a CPT code, for example 29827 - 22 (arthroscopic rotator cuff repair, a massive cuff tear in an obese patient) or 2) more than one modifier, for example, fracture care that will require a second procedure in a morbidly obese patient – 27506-22-58.

Documentation is of the utmost importance. You must substantiate the modifier in the operative or service report. Who and what was provided must be identified. Explain why you are using the modifier and a separate letter or paragraph will increase your likelihood of reimbursement.

Modifier Breakdown

• E&M - 21, 24, 25, 26
• Altered Services - 22, 52, 53
• Assistants - 80, 81, 82
• Pre & Post-op Care - 54, 55, 56
• Multiple Surgeons - 62, 66
• Add-on - 47
• Multiple Procedures - 50, 51, 59
• Repeat Procedures - 76, 77, 78, 79
• Miscellaneous - 57

Coding Center

Coding for the treatment of closed fractures is sometimes confusing. Hopefully, we can simplify this for you and provide the rationale for the coding. Closed treatment is either with or without manipulation and it is appropriate to list an E&M service with the fracture charge. A 25 modifier is listed with the E&M service. The exact E&M code is dependent on the level of service and the location. We want to review the two options the surgeon has for coding the fracture care. We can use global billing with a 90 days global or episodic/ itemized billing with no global. The American Academy of Orthpaedic Surgeons (AAOS) believes it is imperative that the treating surgeon have the latitude to choose the most appropriate option. There are often several variables such as co-pays, insurer policies and the amount of time and effort required to provide care that are important in your decision regarding billing options. The benefits of global billing include fewer claims/dates of service to adjudicate and cheaper/less administrative/staff processing. However, episodic billing is more appropriate for fractures that are minimal, require minimal follow-up or require a minimum of your expertise. So feel safe coding fractures as per contract instruction or by either the global or episode method.

In the next several coding corners we will address the correct use of modifiers. Let us set the ground work with definitions and the why/who/when (s) of modifiers. Modifier Definition – "…indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code." AMA Physicians’ Current Procedural Terminology – Richard J. Freidman, MD, presentation at the "Coding and Reimbursement Update 2008" Chicago, IL.

Why modifiers are used to : 1) Clarify services reported when they vary from the normal service descriptor; 2) Protect your correct reimbursement; 3) Prevent delays in payment; and 4) Prevent denials and costly/timely resubmissions and appeals.

When modifiers are used to: 1) Separate professional and technical components; 2) Service provided by more than one physician; 3) Service had increased or decreased level of service; 4) Indicate an adjunctive service; and 4) Indicate a bilateral procedure.

When modifiers are also used for: 1) Multiple procedure or same procedure performed more than once; 2) Service(s)/procedure provided within the global services period of another service/procedure; 3) Indicate occurrence of unusual events. Use modifiers "pro-actively" and make them a part of your coding regimen. Modifiers are used for any and all health care providers.

Modifier formats are: 1) a two digit appendage to a CPT code, for example 29827 - 22 (arthroscopic rotator cuff repair, a massive cuff tear in an obese patient) or 2) more than one modifier, for example, fracture care that will require a second procedure in a morbidly obese patient – 27506-22-58.

Documentation is of the utmost importance. You must substantiate the modifier in the operative or service report. Who and what was provided must be identified. Explain why you are using the modifier and a separate letter or paragraph will increase your likelihood of reimbursement.

Modifier Breakdown

• E&M - 21, 24, 25, 26
• Altered Services - 22, 52, 53
• Assistants - 80, 81, 82
• Pre & Post-op Care - 54, 55, 56
• Multiple Surgeons - 62, 66
• Add-on - 47
• Multiple Procedures - 50, 51, 59
• Repeat Procedures - 76, 77, 78, 79
• Miscellaneous - 57