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Rib Fractures and modifiers

  1. #1
    Default Rib Fractures and modifiers
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    I have a trauma practice that has ALOT of billing for rib fractures. My issue is trying to make Medicare happy by billing the correct modifiers and get them paid. I have called Trailblazer and they are clueless...Bless their hearts!!! Any help w/b appreciated...

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    Bill the first 21800 and then all other rib fractures use 21800-59. Make sure you use the dx code 807.01 for each 21800.

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    I have a denial for a claim in 2014 for 21800. There were 4 rib fractures, the first was paid, but the 2nd through the 4th are denying as duplicates. The subsequent rib fractures were billed with a -59 modifier on each(separate lines.. 1 unit), but are still denying. Should the -76 modifier be used? Also, I have a question about the dx codes. If we are billing 4 fractures on separate lines, should the dx code be for 1 rib fracture (807.01) or 4 (807.04) per line item?
    Thanks,
    Toya

  4. #4
    Location
    Nashville AAPC Chapter
    Posts
    937
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    I just did a check in encoder pro and you do not need a modifier 59 on subsequent lines after your first as multiple 21800, I checked as the coding tip states bill multiple fractures on separate lines with modifier 51. I know...messes with our logical coding brains doesn't it?

    Just a side note:
    Our ER coders bills the code on a single line with multiple units depending on how many ribs are fractured and they pay without denials and link the dx code(s) correctly on the claim.

  5. #5
    Location
    Hartford, CT
    Posts
    723
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    This is from the NCCI Policy Manual, Chapter IV Musculoskeletal, Section F, #14: If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported. Additionally, if a single cast, strapping, or splint treats multiple fractures without manipulation in addition to one or more fracture(s) with manipulation, a closed fracture without manipulation CPT code should not be reported separately. These policies also apply to the closed treatment of multiple fractures not requiring application of a cast, strapping, or splint.


    You stated that this patient is Medicare, so based on the NCCI policy manual Medicare will not pay for more than one rib fracture.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  6. Default
    Thanks OCD_coder for your response. I checked Encoder Pro as well for this procedure and it does say to bill separate lines with modifier 51. Also, the Medicare contractor here in GA (Cahaba) states that the MUE is 1, so we can only bill 1 unit per line.

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    Thanks dclark7 for this information. I'm going to pull up this NCCI policy.

  8. #8
    Location
    Nashville AAPC Chapter
    Posts
    937
    Default
    Toya,

    MUE limit means per day, not per line. So you can only bill the CPT code only once for that injury event.

    Addendum:
    Excellent information from dclark, of course I was unaware that we don't bill fracture codes to Medicare in the ER, we only bill the casting with an E&M service. We've just had too much headache with appeals.

  9. #9
    Location
    Hartford, CT
    Posts
    723
    Default
    I would just like to say that many people check the NCCI edits but forget to check the policy manuals. CMS has a NCCI policy for each chapter in the CPT book. Sometimes an edit will show that you can bill codes together but when you check the policy manual CMS won't pay for a variety of reasons. I try to check the manuals each quarter when the new edits come out, but if I forget and see alot of the same denials I make sure to go and double check.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

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