Wiki E/M with closed fracture treatment

[dovejsd]

I have NO ortho experience so I am appealing to you ortho coders:

When billing for fracture care in the office one of our ortho providers bills an E/M with modifier 57 and then the code for the fracture care. (ex: 99213-57 and 27530) Our billing system does not like the modifier 57 and wants a modifier 25 used. The provider is insisting that since the fracture care has a 90 day global period that modifier 57 should be used. I need to know which modifier is correct, and where I can find the documentation to support the answer.

Thanks so much!

 

[JenLawson]

Modifier 57 indicates that a decision for surgery was made. If this is the case then 57 is a correct modifier. If not then 25 would likely be the modifier to use.

In the CPT book there is a quick reference for the modifiers inside the front cover, if you want the full description you need to look in appendix A near the back of the book.

 

[scooter1]

per Supercoder.com

General Surgery Coding Alert
Modifier -57 Gains Payment for Preoperative Exams


Medicare guidelines stipulate that evaluation and management services provided the day before or the day of a major surgery (i.e., a surgery with a 90-day global period) are included in the surgery's global package and are not separately reimbursable. If the preoperative exam prompted the decision for surgery, however, separate reimbursement is warranted and may be achieved if the visit is properly documented and modifier -57 (Decision for surgery) has been appended

 

[pittiemom2722]

Your provider is correct. If a procedure has a 90-day f/u period, modifier 57 is added to the E/M code, as is in this case with a fracture. If a cast is applied during the initial visit, you also bill for the supplies. Subsequent cast changes during the global period, bill for the cast application and supplies along with any x-rays done.

If a procedure is considered "minor", 10-day global period or less (i.e., injection), modifier 25 is added to the E/M {If a patient is scheduled to come in for a planned injection, i.e. viscosupplement, then only the injection/medication codes are billed - no E/M}.


Kris, COSC