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opinions needed

  1. #11
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    Medical Coding Books
    You are so right...no black and white in the coding world!!

    Be sure to save all of this documenation/articles/examples to back you up. I've actually been coding with the -57 modifier for many years and fortunately have never been dinged for it in any of the audits I've been through. The outside auditors/compliance are the ones that like to ding for it because it is considered "undercoding" or lost revenue in their eyes.

  2. #12
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    Duluth, Minnesota
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    mbort - that's good to know! I was wondering about how auditors would view the use.
    Could you clarify though, do you "always" code an E/M and modifier .57 with the fracture treatment? Or is it only when/if there are other UNRELATED issues are going on that are being addressed? Much like we would use a .25 on E/Ms the same day as minor UNRELATED procedures.

    thanks!
    Donna, CPC, CPC-H

  3. #13
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    Providing the documentation supports an E/M (sometimes some of my guys are lazy and don't deserve it) yes, I almost "always" bill the e/m with the -57 and the fracture code. The only carrier that I can think of off the top of my head that does not pay for it is Medicaid. Other than that, we have no issues with getting paid.

  4. #14
    Location
    Milwaukee WI
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    Default Yes, 99213 with 57 modifier & fracture care
    Our compliance office agrees with Nancy's compliance office ... For those cases where fracture care is provdied in the clinic/office setting without a trip to the OR ... if the patient arrives with a complaint but no definite dx of fracture, and the physician is evaluating the patient and determining there is a fracture and then treating it, we code the appropriate level E/M with -57 modifier and the fracture care (which carries a 90-day global period).

    If the patient has already been diagnosed with a fracture (by ER or perhaps PMD) and the ortho service is being asked to treat, we just code the fracture care.

    As always, documentation needs to support the services billed.

    F Tessa Bartels, CPC, CPC-E/M

  5. #15
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    Duluth, Minnesota
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    FTessaBartels, thanks for the response! (I was wondering when you'd respond!) I still don't see the logic in using .57 (though, I know, I know the "guidelines") lol... I'm researching this quite extensively now, it seems to be a matter of opinion as to whether or not an office visit gets charged with the initial fracture care. Some view in much the same way as a lesion removal -if that's all they're having done, all they're having looked at and attention to, then that's all that's coded, no office visit - just the lesion removal code... they feel the same for fracture care, of course it hasn't been diagnosed until after xray, being looked at - but if it's the only thing being looked at, the only thing being determined and placing the initial cast and planning the followups - they tend to bill/code only the fracture treatment code, no office visit. In both instances the exam and procedures are inclusive to the care, they "have" to look at the lesion and decide how to take it off, just like they "have" to do an xray to determine the extent of the injury. (obviously, I lean towards their way of thinking & interpretation of the guidelines). Most that I've found, will use .25 modifier on the E/M "IF" there is another issue addressed, something unrelated to the fracture care and treatment. Some I've found will use the .57 modifier in those instances. I've always used the .25 in the past, but only if there was something above and beyond the fracture treatment. I do believe I'll start to use the .57 (even though I don't agree with it), because of the 90day global rule. But, I'll only use it if there's something other than the fracture care and treatment going on with that visit.
    {that's my game plan at this time anyway!}

    thanks again to ALL for responding with your opinions, I REALLY appreciate it, it's been VERY helpful!
    Donna, CPC, CPC-H

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