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Major Procedure Always First?

  1. #1
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    Capital Coders, Columbia, SC
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    Default Major Procedure Always First?
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    My physician performed a 28470 (closed treatment metatarsal fracture) and 11760 (repair nailbed) in the office. The 11760 = 6.21 RVU's and is a minor procedure with 10 day global. The 28470 = 6.03 RVU's and is a major procedure with 90 global.

    1. Typically, we report the higher valued procedure as the primary procedure. Does anyone know of any rules which state the "major" procedure must be reported as primary, even if it has a lower RVU?

    2. The physician also performed significant, separately identifiable evaluation & management in addition to the usual pre-operative care of the procedures, in which the decision for surgery was made. Would it be appropriate to append both modifiers 25-57?


  2. #2
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    Quote Originally Posted by halebill View Post
    My physician performed a 28470 (closed treatment metatarsal fracture) and 11760 (repair nailbed) in the office. The 11760 = 6.21 RVU's and is a minor procedure with 10 day global. The 28470 = 6.03 RVU's and is a major procedure with 90 global.

    1. Typically, we report the higher valued procedure as the primary procedure. Does anyone know of any rules which state the "major" procedure must be reported as primary, even if it has a lower RVU?

    2. The physician also performed significant, separately identifiable evaluation & management in addition to the usual pre-operative care of the procedures, in which the decision for surgery was made. Would it be appropriate to append both modifiers 25-57?

    Medicare has a policy...

    7. Base payment for each ranked procedure on the lower of the billed amount, or:

    • 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;

    • 50 percent of the fee schedule amount for the second highest valued procedure; and

    • 25 percent of the fee schedule amount for the third through the fifth highest valued procedures;

    Page 110

    http://www.cms.gov/manuals/downloads/clm104c12.pdf

    As for the 2nd question, I have had those very same scenarios and did add 25/57 when there was a separate, identifiable E/M and a major proc.

  3. #3
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    Capital Coders, Columbia, SC
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    Thanks, Rebecca! It looks like that is the route I will take on this one. It's interesting that it took six years for me to run into this scenario.


    Bill

  4. #4
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    North Carolina
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    Quote Originally Posted by halebill View Post
    Thanks, Rebecca! It looks like that is the route I will take on this one. It's interesting that it took six years for me to run into this scenario.


    Bill
    I know what you mean. It doesn't happen frequently to me, either but this is the method I follow when it does.
    Last edited by RebeccaWoodward*; 09-27-2011 at 01:04 PM. Reason: spelling

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