Orthopedic Coding Alert

Question: When a patient presents with a fracture and the physician spends thirty minutes trying to reduce the fracture (closed) but has to complete the procedure (open), should we code for the closed procedure with modifier -52 and for the open procedure? Or, should we not code for the attempted portion?

Billie Jo. McCrary, CPC, CMPC
Cincinnati, OH

Answer: The coder must distinguish between two alternatives. Was the attempt to reduce the fracture (closed) abandoned because of the anatomy of the patient? If so, use modifier -52 (reduced services). Or, was it terminatedi.e. cancelled? If this is the case, use modifier -53 (discontinued procedure).

Since the closed approach did not enable the reduction, and the procedure was discontinued in favor of another approach, -52 is the appropriate modifier.

If a -52 modifier is used, extensive documentation, including office records and test results, must be submitted with the claim.

Note: Neither -52 nor -53 applies if the patient requests termination.

After attaching the modifier, also bill for the service that was completed. Be sure to do so using a modifier -78 (return to the operating room for a related procedure during the postoperative period.) The payer will decide how much (if any) reimbursement the provider gets for the service that was discontinued.

Note: Modifiers -52 and -53 apply only in a hospital setting. For outpatient services see modifiers -73 and -74. The July 1999 Orthopedic Coding Alert considers the ins and outs surrounding modifiers -52 and -53; see page 49, Optimize Failed Procedure Reimbursements.