Orthopedic Coding Alert

Modifier -32 (Mandated services) describes procedures or services required by a third-party payer, governmental or legislative agency, or regulations. The modifier is often used when college athletes present for preseason physicals.

Third-party payers may require an orthopedist to render a second opinion before the carrier will approve surgery. For example, Orthopedist A has determined a patient needs an arthroscopic SLAP repair (29807, Arthroscopy, shoulder, surgical; repair of SLAP lesion). Before the carrier approves the surgery, it requires Orthopedist B to conduct a physical examination of the patient. That visit, e.g., 99243 (Office consultation for a new or established patient ), is appended with modifier -32 to signal the carrier that the consult was initiated at the payer's request and is not a redundant claim.

Modifier -32 may also be used by an orthopedist who conducts preseason sports physicals for college athletes. Without the modifier on the claim, carriers might balk at a routine examination for an otherwise healthy, asympto-matic patient. But modifier -32 indicates that the visit is a service mandated by the college prior to the patient's participation in sports. According to the American Medical Association, if the physician performs a comprehensive history and examination, the age-appropriate preventive medicine codes apply (e.g., 99385 or 99395, Initial/periodic comprehensive preventive medicine evaluation and management of an individual ). If the physician limits the service to a problem-focused, expanded problem-focused or detailed history and examination, then the appropriate level E/M Code applies (e.g., 9920x or 9921x, Office or other outpatient visit for the evaluation and management of a new/established patient ).

Second opinions or confirmatory consultations requested by the patient or the patient's family do not qualify for modifier -32 and are almost always an out-of-pocket expense for the patient.