Rely On Modifier 54 When You’re Breaking Up Fracture Care

Posted on 27 Sep, 2015 |comments_icon 5|By Chris Boucher

If physician provides operative care only, you’ll need modifier to clarify claim.

When your physician provides fracture care for a patient, but does not follow up with any postoperative care, coders need to be ready to append modifier 54 (Surgical care only) to the fracture care code in order to code the encounter correctly.

Consequences: If your physician does not provide any follow-up care for a fracture patient and you neglect the 54 modifier, payers will become suspicious.

When the physician provides only operative care “a 54 modifier would always be required if the fracture code has a 90 day global period attached,” explains Sharon Richardson, RN, compliance officer for E/M services at Emergency Groups’ Office in San Dimas, Calif.

Perhaps the most common instances in which you’d use modifier 54 are when a patient is injured away from home, or the fracture requires immediate care — such as over the weekend or on a holiday.

Example: A patient reports to your physician with a right ankle fracture he sustained while snowboarding on vacation. The physician surgically repairs the ankle, and tells the patient to complete follow-up care with his local orthopedist. On the claim, you would report 27814 (Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed) for the fracture care. Then append modifier 54 to show that you are only coding for the surgical care.

There are also instances in which the physician on hand can repair the fracture without the aid of a specialist, but does not engage in the aftercare.

See Also: Avoid Denials for Unrelated Postop E/Ms with Modifier 24

Example: A patient presents to the ED after a fall in which he used his forearms to brace himself. During a level-three ED E/M service, the physician discovers a non-displaced right distal radial fracture. The physician calls the orthopedist, who says he does not need to see the patient emergently. The physician splints the patient’s forearm, prescribes pain medication and instructs the patient to follow up with an orthopedist for postoperative care.

On this claim, Richardson says you should report 25600 (Closed treatment of distal radial fracture [e.g., Colles or Smith type]) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) for the fracture care with modifier 54 appended to show that you are coding only for the surgical care.

Also, report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) for the ED E/M service with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery) attached, depending on the payer.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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