Part B Insider (Multispecialty) Coding Alert

Published on Thu Jan 27, 2005 PDF

Provide justification if you bill more than one code

This little piggy has a stress fracture, and this little piggy has a complex fracture. The physician performs a closed reduction on both toes, and only applies a single cast to both metatarsal fractures. Can you bill more than one global code?

The answer is a judgment call, say coding experts. How many codes you can bill depends on whether the physician performed a non-manipulation (CPT 28470 ) or manipulation (28475) reduction. Another consideration: How likely the physician believes each fracture is to develop separate complications during the 90-day global period.

The CPT definitions for both 28470 and 28475 say "each," meaning that you should bill one unit of either code for each fracture, says Mary Brown, coding specialist for Ortho West in Omaha, NE. But her physicians will often bill only one global code for multiple closed reductions on the same foot, she notes. "It's kind of a doctor's discretion."

If you bill the same global code more than once, you should use modifier -51 (Multiple procedures) and expect the carrier to reduce the payment for the second code by at least 50 percent, notes Brown. "They'll probably just pay you the intraoperative portion of that code."

Consider Itemized Billing for Non-Manipulation

When the physician performs a non-manipulation reduction on two toes and applies one cast, billing for each toe can be "hard to justify," says Margie Vaught, a coding consultant in Ellensburg, WA. This can add up to a $1,800 bill for a single cast, she notes. Instead of reporting a global code for minor, non-manipulation reductions you may want to bill on an itemized basis for cast application and evaluation and management services, she adds.

But for a closed reduction with manipulation, you should bill separately for each reduction, Vaught says.

Often each toe will have its own potential complications, notes Alameda, CA, podiatrist Anthony Poggio. One toe could have a non-union fracture and another could fail to heal in some other way, he points out. Also, one toe may require manipulation and the other one won't. "They're two separate entities and you bill for each," he insists.