ED Coding and Reimbursement Alert

Question: A patient presented to the emergency department (ED) with a fracture of the greater tuberosity of the humerus and anterior shoulder dislocation. The orthopedic surgeon was consulted after x-rays confirmed the diagnosis. One of the ED physicians assisted with the reduction of the dislocation. The procedure was performed in the ED after the orthopedist had ordered conscious sedation. Can I bill this procedure with the appropriate CPT code and modifier -81 to indicate minimal assistance of this closed procedure? If so, I will verify with the orthopedist whether or not to indicate manipulation of the greater tuberosity fracture in the code to be used.

Cheryl Goodrich
Morgantown, W.V.

Answer: The ED physician may report assisting in the shoulder reduction; however, medical necessity may be an issue, says Penny Lodes, CPC, independent coding consultant in Appleton, Wis. Many carriers may not allow an assistant for closed fracture/dislocation reduction. Do not use modifier -81 (minimum assistant surgeon) unless specifically indicated by carrier for a specific use. Always use modifier -80 (assistant surgeon) for a physician assist.