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17 Orthopedic Coding Questions Answered By Stephanie Ellis

During and following a recent audio conference on orthopedic coding, Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting, responded to questions about challenging orthopedic coding issues from participants in the program. The following are her responses to 17 of these questions.

1. Q: May I have clarification on -74 and -73 modifiers? May we bill the insurance carriers if the termination of a procedure (both before anesthesia and/or after anesthesia) is in the pre-op area? This is our prep area (where IVs are administered) but not the procedure room where the surgery will be performed?

Stephanie Ellis: Medicare has strictly directed that patients must be in the OR or the procedure room where the procedure is to be performed when the procedure is cancelled or terminated in order for the procedure to be billable to Medicare using the -73 or -74 Modifiers. If it is not a Medicare patient, you would need to check with that payor for their guidelines on this situation and if the case would be billable with the -73 Modifier if the patient were not in the OR/procedure room where the procedure was to be performed.

2. Q: I would just like to confirm my interpretation for use of the -SG modifier. We use the SG modifier for work comp claims. It is my understanding that the SG should not be used with CPT 99070. Is this correct?

SE: Yes. In the rare cases where you would still use the –SG modifier (since it is not necessary on Medicare claims for dates of service in 2008), the –SG modifier would also not be used on HCPCS implant codes (such as L8699) or on radiology codes (such as 77003-TC for fluoroscopy).

3. Q: Would the -SG modifier be used on 77003?

SE: No. The -SG modifier is not used on implant or radiology codes unless the payor specifically requires its use.

4. Q: Can you please tell me if release of right triggers for thumb, ring and small finger would require a -RT modifier or modifiers for each finger?

SE: Use the finger modifiers on trigger finger release procedures, rather than the -RT or -LT modifiers.

5. Q: Would I be able to use the –GY modifier on the implant line to see if that would make any difference on the denial from Medicare. I really don't want to put the -GY on the secondary insurance line, only Medicare. Is it okay to do this?

SE: It is okay to bill Medicare with the -GY non-covered modifier and the use of that modifier might speed up the denial, but whether or not the secondary payor would have
a problem with the claims not being billed the same, you would have to check with the secondary payor to find out. As a matter of habit, I would usually not append the –GY Non-covered Modifier to Implant codes. Its use will cause unnecessary implant denials.

7. Q: Our surgeon inserted a I-Flow ON-Q PainBuster post-op pain relief system for each of these groups of surgeries:

a.) 29826, 29824
b.)29827, 29826 and 29824
d.)29826, 29824 and 29822.

The surgeon isn't billing any extra for the insertion of the pain pump. We basically quit billing for this service as well. The actual I-Flow pain pump itself, the manufacturer is billing the insurance carriers for the actual piece of equipment. Can the ASC bill a code for the surgeon inserting the pain pump for these shoulder cases?

SE: Pain pump insertions or individual injections given for post-op pain relief are only billable (64415 for injection/64416 for pain catheters with a pump) when they are performed by a physician other than the orthopedic surgeon performing the surgery (usually an anesthesiologist). If the ASC is trying to bill for the use of the pain pump equipment itself, Medicare will not reimburse for that, but you can try to bill other payors — it would totally depend on the payor and their individual policies for coverage of the use of equipment separately from the surgery itself, and most payors (particularly if you are contracted with them) would not cover that separately. It sounds like the equipment company is billing the payor for the use of the pump, from the example given, so there is really nothing for the ASC to bill on that, in my opinion.

8. Q: How do ASCs set their usual and customary rates?

SE: They are usually determined based on their costs to do the procedure (staffing, equipment, supplies, length of time in the OR and PACU, etc.) or based on some percentage mark-up of what Medicare pays for the procedure.

9. Q: We are billing the exact same procedure code that the surgeon has, but billed for the ASC and implants if billable. Should we be billing for any other services such as medicines, drugs, etc.?

SE: You can break out your charges for drugs, anesthesia time, OR time, recovery room time, etc., only if the payor allows you to break charges out like hospitals do. If your facility is contracted with the payor, they usually will not accept bills with detailed charges such as this from ASCs. It is based on what the payor will and will not allow you to do. Most payors who contract with ASCs are expecting to pay for the CPT codes and implants only — and some won’t even pay for all the CPT codes billed and may or may not cover the implants.

10. Q: For Medicare patients, the surgeon and ASC have decided to go ahead with shoulder surgeries when Medicate is primary. We know that Medicare doesn't cover the implant. I've still been billing for the implants under the ASC, but having a real hard time getting a valid/correct denial from Medicare to submit to the patients second insurance. Some of these secondary insurances, if not a Medicare supplement, may pick up the implant, but we can't seem to get a valid denial. What is everybody else doing, because we are basically having to write the implants off?

SE: You need to check with the payor about why you can’t get an explanation of benefits (EOB) with the denial so you can bill the secondary payor. If you can’t get a satisfactory answer, work your way up the ladder at the payor to a supervisor or manager and explain the situation and get some help.

11. Q: I've been using only one orthopedic implant code — L8699 — for all of the implants we're doing. Does that sound correct?

SE: There are not many implant codes for use in the billing of orthopedic implants. Using L8699 or 99070 usually work well. The reimbursement on orthopedic implants totally depends on the payor’s policies about covering them.

12. Q: It is often not clear what carriers want us to use the -SG modifier. Originally only Medicare wanted -SG. Now Medicare does not recognize that modifier Harvard Pilgrim requires it.

SE: ASCs should not use the -SG modifier on Medicare claims for dates of service in 2008. If Harvard Pilgrim requires the -SG modifier, then use it on their claims. In many states, Medicaid claims require it because they are billed on CMS-1500 claim forms. On claims filed on CMS-1500 claim forms, many times it is a requirement to use the -SG modifier to be paid correctly. It would not be used on Medicare claims, though. This is a payor-specific guideline and the ASC would need to check with the payor to find out if it is required. ASCs should not use the -SG modifier on claims filed on UB-04 claim forms, unless it is required by the payor.

13. Q: I have been told to not use modifier -51 at the ASC for multiple procedures. Is this correct?

SE: Yes. The -51 modifier is a physician modifier only and should not be used on ASC claims, unless specifically required by the payor,

14. Q: Is modifier -59 to be used for all multiple procedures in a ASC?

SE: No! It is only to be used when a code is unbundled in the CCI material and the procedure is performed in a separate compartment/separate area/separate Incision, or the code has “separate procedure” status in the CPT book and the procedure was performed in a separate compartment/separate area/separate incision. Do not use it like the -51 modifier would be used on physician claims.

15. Q: Most of our carriers can only read one modifier. Which is more important: the -59 or the –SG modifier? Our claims are not denied but they are delayed.

SE: The -SG modifier (when it is required) is always placed before the -59 modifier. If you have a denial, file an appeal on the claim. You shouldn’t be using the –SG modifier on many claims for ASCs now, though.

16. Q: We are going to be doing a Topaz treatment for plantar fasciitis. How do you recommend we code this procedure?

SE: From my research, there is no code for this procedure and the 28899 “unlisted code” should be used. Since Medicare no longer accepts unlisted codes, these procedures should probably not be performed on Medicare patients in the ASC setting.

17. Q: Not necessarily ASC related, but physician coding: If 22612 is the primary procedure, what are the rules about the billing of the following codes more than once in conjunction with 22612:

  • 22851
  • 95937
  • 22614

For 22851: If two cages are used in the procedure, bill the 22851 code a second time with the -59 modifier.

For 95937: This code is unbundled in the CCI material from the 22612 code and should not be separately billed to Medicare. It is your discretion if you decide to bill it to workers' compensation or other payors.

For 22614: If a fusion is performed at three levels, this code would be
used more than once. For example:

  • 22612 - 1st level
  • 22614 - 2nd level
  • 22614-59 - 3rd level

Note: CPT codes are copyright by the American Medical Association.

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