Wiki Planned ORIF following CLOSED RED w External Fixation

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dimplez

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Ok - am I losing my mind? Is it not appropriate to report a closed reduction with the application of an external fixation even when the ultimate plan is to return the patient to the OR for an ORIF? Yes, I understand that a modifier (58) will need to be applied to the return. An example would be if a patient has a complicated open fx and they do debridement, closed reduction and ex fix - several times - and THEN do the final ORIF. My thoughts are what if the patient dies before they can bring the patient back for the final ORIF - you lose the initial reduction. Another situation would be what if the pt NEVER returns.......weird, but I have seen it happen. (pt's fx wasn't open, but they had to wait for the swelling to go down)

Does anyone have like an AAOS article or some type of resource on this? I am getting push back on this......HELP?????
 
It is always appropriate to report closed reduction and external fixation when it is performed, even if it is not the definitive fixation. If there is a planned return to the OR, then using the -58 modifier on the follow up procedure is appropriate. This would reset the global period to begin on the date of the second procedure but would not limit reimbursement from the second procedure.

Who are you getting pushback from, and why?
NCCI pretty clear that restrictions on billing a secondary fracture procedure only apply when they are performed at the same setting, and that does not apply here.
 
Not the surgeons, but the coding supervisor and manager. I am new to the organization (as a SME/liaison for the surgeons) and have identified that they are not doing that for trauma patients...the operative notes even state that the fx is aligned with tightening of the external fixators. On one patient, they did not return, so revenue lost. :( So now I am like I am like just because it was the plan, it doesn't always mean that it will happen.
 
Do they have some justification for this?
I don't see how -not- billing appropriately for this would be consistent with CMS/NCCI or AMA/CPT policy.
 
You are correct and not losing it. Especially in ortho trauma. You would expect to see multiple coding of these type with definitive fixation later. What you described with massive swelling, open fractures, multiple debridements, and ex-fix pending final definitive fixation later is exactly the reason why you would see and code this. It is also possible to see multiple times where they have to revise or adjust the ex-fix. They might be doing debridement multiple times too until the soft tissue, etc. is ready for them to close and do ORIF.
They are mixing DEFINITIVE/FINAL fixation with the fact that these trauma patients have to go back in multiple times especially with big open fractures. Or even complicated, closed fractures. You also can't mix the concepts applied in the office setting with trauma cases. You would expect to see many modifier 57, 58, 59, 79, 78, 24, 25 in big trauma cases where they may be IP for days or weeks. I bet you they are losing money on rounding/subsequent hospital E/M on the patients too if conditions and issues not related to the global are being addressed separately. If a patient had multi-trauma and ortho is addressing multiple anatomic areas (UE, LE) but only did surgery on one area for example. Depending on your practice you could have spine, hand, foot & ankle, and a joint guy all seeing the same patient IP.

I assume that's why the surgeons want your help. I agree with Dr. Raizman, what is their justification for this? What documentation or backup do they have? Just because "they said so"? They brought you in as a SME but won't listen? :) :) :)

This is old but may have resources: https://www.aapc.com/medical-coding...KETmsd1G4pmO48jfRee-7rKfE-JHGb_j2MqrcUbb44ADk
 
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