ED Coding and Reimbursement Alert

Question: We are considering billing fracture care with a modifier -54 (surgical care only) to show that the physician is only doing the initial care and referring the patient to an orthopedist for follow up. Will adding modifier -54 be the best way to appropriately optimize reimbursement?

Florida Subscriber

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Answer: You get 79 percent of the total Medicare Fee Schedule reimbursement if you use the -54 modifier with the surgery/musculoskeletal series 20000 codes and 81 percent for the surgery/integumentary 10000 series codes. You can use modifier -54 as long as the initial care provided in the ED is fracture or restorative care. For example, splinting a wrist fracture (29125, application of short arm splint [forearm to hand]) so the orthopedist can reduce and cast it in the morning is not fracture care. And, orthopedists will often bill full fracture care for patients even though the ED physician provided the restorative care.