Orthopedic Coding Alert

Here's how many, but not all, payers now deal with 51 claims.

When an orthopedic office provides care for a patient, there is always the chance of separate services: an evaluation and management (E/M) service might precede the surgical procedure, or the physician might perform more than one fix during the same encounter.

Do this: Remember that there are several modifiers that could accompany these multi-code treatment claims; among them modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), 59 (Distinct procedural service), and/or 51 (Multiple procedures).

Check out this expert input on how to use each of these modifiers correctly when a patient comes calling for treatment.

Be Sure of Separate E/M for 25 Encounters

Some coders might assume that almost all procedure claims include an E/M with modifier 25. This is a dangerous assumption for three reasons, experts say:

1. Many separately reportable E/Ms before orthopedic care involve a "major" surgery, which translates to a CPT® code with a 90-day global period. When the provider performs a presurgical E/M followed by a procedure with a 90-day global period, then you'll append modifier 57 (Decision for surgery) to the E/M.

2. If the provider does perform E/M services prior to a procedure that CPT^® considers "minor," you must make sure that a full, separately identifiable E/M preceded the surgery. Remember, there is an inherent E/M included in all procedure codes, and your provider's service must exceed this service in order to report an E/M-25 along with the procedure code. If you're unsure whether a separately identifiable E/M accompanied a given treatment, check with the provider before filing the claim.

3. You must be sure of the code's global period before choosing modifier 25. "As 57 is applied for 90-day global periods, 25 is applied for 10-day global periods or less and follows the same guidelines requiring medical necessity for separate reimbursement," confirms Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, N.J. Be sure you are applying modifier 25 to E/Ms that accompany surgeries with "minor" global periods, or you'll miscode the claim.

The distinction between claims where you should use 25 or 57 is often overlooked, explains Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

"Even a closed treatment of a fracture without manipulation is considered a surgical procedure and the choice of modifier - either 25 or 57 - would depend on the number of days in the surgical package," confirms Brink.

Remember: Modifier 25 is for E/M codes only. If you're contemplating filing a fracture care code - or any other procedure code, for that matter - with modifier 25 appended, don't.

Rely on 59 to Break Bundles

Speaking of procedure codes, there are a couple of modifiers you might need when reporting more than one procedure code during your provider's service.

First, let's look at modifier 59. Rogers says that modifier 59 is "commonly used and commonly misused. This modifier essentially tells the insurance company to unbundle what is typically bundled, or included within another procedure." Modifier 59 is not for use on any E/M code; it is strictly for procedures.

Here's a quick example of proper modifier 59 use:

The orthopedist performs an arthroscopy on a patient's right knee, which includes medial meniscectomy and debridement. In a separate compartment in the patient's right knee, the orthopedist performs an arthroscopy to remove a small foreign body. For this encounter, you would report:

• 29881 (Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed) for the arthroscopy with meniscectomy
• modifier RT (Right side) appended to 29881 to indicate laterality, if the payer requires it
• 29874 (...  for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)) for the arthroscopy with foreign body removal (FBR)
• modifier 59 appended to 29874 to show that the arthroscopy for FBR was a separate procedure from29881
• modifier RT appended to 29874 to indicate laterality, if the payer requires it.

Explanation: Typically, 29874 would be bundled into 29881, per Correct Coding Initiative (CCI) guidelines. Since these arthroscopies were distinct procedural services occurring in separate compartments of the patient's right knee, you can unbundle them and code them separately in this instance - using modifier 59 to indicate that you are breaking apart codes that are typically bundled.

The X factor: Each year, more payers are switching to the X modifiers; these are a more specific set of modifiers that are meant to replace modifier 59. The X modifiers are:

• XS (Separate Structure)
• XE (Separate Encounter)
• XP (Separate Practitioner)
• XU (Unusual Non-Overlapping Service)

Best bet: If you're unsure of your payer's stance on modifier 59/X modifiers, be sure to check your contract before filing a claim with distinct procedural services.

Employ 51 when Necessary

Much like modifier 59, modifier 51 is not for use on any E/M code; it is strictly for procedures. "The function of modifier 51 is to identify the additional procedures or services being performed at the same operative session, by the same individual provider, as the primary procedure or service," explains Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC, in Indianapolis.

Apply modifier 51 to the secondary procedure, as determined by relative value units (RVUs) or the "complexity" of the procedures. In short, the less work-intensive, less valuable, procedure should be your modifier 51 code.

Exception: If the procedure code is an add-on code, it would be exempt from modifier 51, Dillon relays.

Extinction? Though some payers still require modifier 51 on multiple procedure claims, the modifier is likely going the way of the dodo bird, experts say.

"Most insurance companies no longer recognize the 51 modifier as it is redundant to their reimbursement structure," says Rogers. "They will automatically reduce reimbursement of the second and following procedures according to the contract agreement."

So, you might not need to worry about modifier 51 for too many of your payers. Don't assume all payers are off of modifier 51, however; be sure to check your contracts or call a rep to get a concrete answer on modifier 51.