Orthopedic Coding Alert

Repetition of a procedure or service may not always mean additional payment

You will often be faced with situations when modifiers are the most accurate way to describe the radiological diagnosis of fractures in the upper limbs. Learning the correct use of modifiers -26, -50, -59, -76, and -77 will help to make sure you are not missing the payment for these when you are obtaining an X-ray to confirm a fracture of the upper limb or its treatment.

Bilateral X-rays May Not Mean Double Payment

You will commonly be faced with a situation where Xrays were requested for both limbs. This is usually done to compare the anatomy. Alternatively, in the case of trauma, say in a road traffic accident, bilateral X-rays may be used to rule out multiple injuries. You may append modifier RT (Right side) and LT (Left side) to the code for the X-ray if the procedure being repeated on another limb. By doing so, you would claim that procedure of examining the injury described by a unilateral CPT® code was repeated bilaterally in the same session.

Example: If you read that after an accident, the patient sustained a fracture in the right collar bone (clavicle) and the attending orthopedic surgeon did a radiological examination in the left collar bone in addition, to rule out an additional fracture, you report 73000 (Radiologic examination; clavicle, complete) and append modifier -50 to claim for the X-ray being performed on the left side. Alternatively, you may use the modifier RT and LT instead of modifier -50. For example, 73000-RT and 73000-LT. "It is more appropriate to use RT (Right side) and LT (Left side) when reporting X-rays," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

You should also make sure the necessity of the X-ray on the asymptomatic or non-painful side is justified by the orthopedist. A bilateral X-ray is often done in children and may not be really necessary in adults. In children, the surgeons often will compare the growth plates in the two limbs to help diagnose a fracture.

"X-rays taken of an area not affected by a condition or an injury for comparison reasons would be coded using the appropriate X-ray CPT® code, but they should be linked with diagnosis code V72.5 (Radiological examination not elsewhere classified). Using this diagnosis code may result in a denial from the carrier, but its correct coding. Taking X-rays for comparison is up to the provider as part of the evaluation and management of the patient's condition,"says Denise Paige, CPC, COSC, orthopedic coder, Bright Health Physicians, Whittier, CA. So, in the example above, you would report 73000-LT and 73000-RT link code V72.5 for the X-ray performed on the asymptomatic side.

Report Services of Each Surgeon

You will need to read for the services of an assisting or another surgeon for a particular procedure. You add modifier -76 (Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service) to the procedure code if the orthopedist performs the exact same procedure twice on the same date. Modifier -76 alerts the insurer that the same procedure was done twice by the same physician. "This is often added for post-reduction films after a fracture reduction in the office or ER," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C. "Repeat X-rays taken after a reduction or surgery would be coded using the appropriate X-ray CPT® code adding modifier --76 to indicate it's a repeat procedure," supports Paige.

You may learn about the role of another orthopedist and select modifier -77 (Repeat procedure or services by another physician or other qualified health care professional: it may necessary to indicate that a basic procedure or service was reported by another physician or other qualified healthcare professional subsequent to the original procedure or service) to the procedure code if the same procedure was done by another orthopedist, though this is less common.

Example: If you read that after diagnosing a fracture on an X-ray, the reduction of the fracture was again confirmed on X-ray, you append modifier -76. A sample procedure note follows: "Under muscle-relaxing anesthesia, a closed reduction was performed and the elbow was extended, distracted, and then gently flexed to lock the fragment in place. The reduction was then confirmed on X-ray." In this situation, you would report code 73080 in addition to 24577 (Closed treatment of humeral condylar fracture, medial or lateral; with manipulation) and you may also append modifier -76 to 73080 to specify that the X-ray was repeated by the orthopedist.

Procure Your Payments for Professional Services

Append modifier -26 (Professional component) if your orthopedist only interprets the X-rays and hence performs only the professional component of the exam, the technical part being done perhaps by the hospital. "Modifier -26 is used to identify the services of a hospital and is not needed for office X-rays," says Mallon. Include modifier -59 (Distinct procedural service.......) for the distinct or independent procedure/service that was performed on the same day.