Redo ORIF 5th metatarsal base

neofasa25

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Good morning, I need help in coding both CPT and ICD-10 codes. I have a patient that had a non union of her 5th metatarsal base. I did an ORIF on it, 2 weeks after surgery she didn't listen to me concerning her non weight bearing status, she fell and broke the entire repair apart.

I need advice on what code I should use, what diagnosis as well as any modifiers needed to redo and re-bill this procedure.

Thanks Dr Buccilli
 

unicorn80

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Was the procedure open or closed treatment? If you didn't specify open or closed treatment in the procedure note and just specified that it was a nonunion repair of the 5th metatarsal base of the left or right foot then your code would be 28322 with the proper modifiers for laterality in addition to either modifiers 22 and/or 76. I was thinking modifier 78 as well but part of the description for when to use this modifier says within the "postoperative period" which is 10 days and the patient didn't return until after 2 weeks post surgery (14-days). The modifiers you would need are for laterality (RT or LT) and a couple of other modifiers I don't know which would be correct but I am thinking if you would describe this as an "increase in procedural services" then you would need modifier 22 and since this sounds like a "repeated procedure or service by same physician or other qualified healthcare professional" you would use modifier 76. The diagnosis codes I know have to relate to the procedure code. You have to also use any external cause codes which would be the cause of the injury, which would be the fall. Your dx code for this would be what was used on the initial claim and the external cause code is the fall. Do you know anything else about the fall so the code has more specificity as to what caused the fall? If it is not known then I would say the fall was accidental in nature and is not further specified, W19.XXXA if this is the initial encounter, W19.XXXD for subsequent encounter or W19.XXXS if it is a sequela. I'm not sure how this encounter would fit the diagnosis considering the circumstances. The final code I feel is needed is one that indicates the patient not adhering to your instructions following surgery. The code for this is Z91.19 "Patient's noncompliance with other medical treatment and regimen".

If I am missing anything here hopefully someone else will come on this thread and add to it but I feel like I covered most if not all what needs to be coded. You shouldn't have to change anything with what was previously coded like the dx and cpt codes should stay the same. Adding the additional codes like the external cause and the factors influencing health status and contact with health services codes are needed to further support the procedure code and the modifiers given. If you are using multiple modifiers to describe the procedure performed also add modifier 99 so the payer is aware of there being more than one modifier.

FYI.....I am a Medical Coding/Billing//Health Information Technology student so trying to help you out with this is good practice for me. I also took my my CPC exam last August and passed.
 
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twizzle

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Good morning, I need help in coding both CPT and ICD-10 codes. I have a patient that had a non union of her 5th metatarsal base. I did an ORIF on it, 2 weeks after surgery she didn't listen to me concerning her non weight bearing status, she fell and broke the entire repair apart.

I need advice on what code I should use, what diagnosis as well as any modifiers needed to redo and re-bill this procedure.

Thanks Dr Buccilli
The operative report is required in order to code it along with pre- and post-op diagnoses. One thing I can say about the previous response is that modifier 76 is definitely incorrect. This is for an exact same procedure on the same day.....this is neither of those.
 

unicorn80

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The operative report is required in order to code it along with pre- and post-op diagnoses. One thing I can say about the previous response is that modifier 76 is definitely incorrect. This is for an exact same procedure on the same day.....this is neither of those.
So would he use the modifier 78 then if modifier 76 is incorrect?
 

twizzle

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Yes, probably 78 although I would need to see the full report to see what the provider says. You would definitely have to say the second procedure was related to the initial procedure.

In addition you said the procedure has a 10-day global which is incorrect. Surgical treatment of a fracture with nonunion is considered a major procedure and therefore has a 90 day global so this would be within the global, supporting modifier 78. Provider stated they did an ORIF (open reduction, internal fixation) so this is an open procedure.

Use of modifier 22 would have to be supported by the documentation. The provider would have to state that the procedure took x amount of time over and above the time the procedure would usually take and they would have to clearly document why it took this extra time in order to support modifier 22. The notes would then need to be submitted to the payer for review.
 
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