Orthopedic Coding Alert

If your Medicare carrier requires modifier 76 instead of 59, here’s what to do.

When you code Lisfranc fracture-dislocation repairs, remember that your coding options rest on whether the surgeon performed the surgery open or percutaneously. Unless you know which method the orthopedist used, you’ll be in limbo between two coding options.

Lisfranc fracture-dislocations are multiple fractures and/or dislocations of the Lisfranc joints — the tarsometatarsal joints of the foot. The injuries usually occur at the base of the metatarsal. Check out the following op note.

Preoperative diagnosis: Left Lisfranc fracture-dislocation.

Procedure overview: The surgeon performed an open reduction/internal fixation of a left-foot Lisfranc fracture-dislocation.

Op Report: Follow the Surgeon’s Notes

The pertinent details of the op note follow: I reduced the fracture-dislocation to near anatomic position, but complete reduction was difficult because of comminution at the base of the second metatarsal. I made an incision along the first and second rays over the tarsometatarsal joint. I retracted the extensor tendons out of harm’s way and identified the area of comminution. 

Using a clamp, I reduced the second metatarsal to its base against the first and second cuneiforms. I then fixed the second metatarsal to the second cuneiform with a single 3.5 cortical screw.

I then reduced the first tarsometatarsal joint anatomically and secured it with another 3.5 cortical screw. Following this, I reduced the third, fourth and fifth metatarsals anatomically and secured them with two 0.062 smooth K-wires. I made final confirmation of the reduction with fluoroscopy.

Coding Advice: Clarify Open Versus Percutaneous

The surgeon in this case study documents reduction of the first through fifth metatarsals, but the only incision he documents is -over the first and second rays.- Therefore, it’s difficult for the coder to tell whether he repaired the third, fourth and fifth metatarsals open or percutaneously.

If the incision was long enough, the other three tarsometatarsal (TMT) joints may have been visualized, but there is a very good possibility that TMT joints three, four and five were fixed percutaneously.

Surgeons perform most Lisfranc fracture-dislocations as percutaneous procedures, says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C. In fact, CMS data shows that orthopedic surgeons perform the percutaneous procedures nearly twice as often as they perform open treatments.

When faced with an op report such as this, the coder should ask the surgeon for clarification. However, we’ve included coding advice for both scenarios below.

Open Procedure? List 5 Line Items

If the surgeon fixed each joint as an open procedure, you should report five units of 28615-LT (Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed; Left side) on separate line items. Append modifier 59 (Distinct procedural service) to the second through fifth line items.

Open With Percutaneous: Use 2 Different Codes

If the surgeon fixed the first and second joints as open procedures, but repaired the third, fourth and fifth TMT joints percutaneously, you should report two units of 28615 and three units of 28606 (Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation). 

Therefore, if the surgeon performed this combination procedure, your claim would appear the following way:

• 28615-LT
• 28615-59-LT
• 28606-59-LT
• 28606-59-LT
• 28606-59-LT. 

Note: Some Medicare carriers now require modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) instead of modifier 59. If you’re reporting to one of those Medicare carriers, you should report: 

• 28615-LT, 
• 28615-76-LT, 
• 28606-59-LT, 
• 28606-76-LT, 
• 28606-76-LT.

Because the Correct Coding Initiative bundles 28606 into 28615, you should append modifier 59 to the line items representing the percutaneous procedures.