Medical Billing ServicesMedical CodingRevenue Cycle Management (RCM)

Understanding Medical Coding Modifiers in Orthopedic Specialization

Problems like injuries, congenital deformities or abnormalities, and diseases concerning the musculoskeletal system fall under the purview of orthopedic treatments. Regardless of the nature of orthopedic specialization your clinic excels at successful billing practices demand that your medical billing specialist is well versed in fulfilling the coding demands relative to the specialty field.

The correct interpretation of information and proper application of codes, modifiers, and extensions facilitates the creation and flawless functioning of a proper revenue stream for the practice by minimizing claim rejections and denials. Following the guidelines put forth by CMS (Centers for Medicare and Medicaid Services), our orthopedic specialist coders provide billing services that pump up your revenue cycle.

The implementation of ICD-10 brought around with it 264 new codes, 143 deleted, and 134 revised codes that apply to coding for an orthopedic practice. New rules related to modifier 59 and the introduction of the applicable modifiers XU, XE, XP, and XS are here to revolutionize orthopedics billing from here. Our team of skilled medical billing professionals displays their understanding of the ICD-10 and proficiency in numerous ways in which the new requirements and coding changes impact orthopedics.

What Are Modifiers & Why Are They Game Changers in orthopedics billing?

By definition, Modifiers are simple two-character designators that signal towards a change in how the code for the procedure or services should be applied for the claim. If put to use strategically, modifiers add to the accuracy and detail to the record of the medical encounter. If misused, they can lead to claim denials, payer audits, and in rare cases investigations, refunds, and fines.

Modifiers are two-digit codes and are categorized into two levels:

  • Level I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and is updated annually by AMA – American Medical Association. These CPT modifiers are used to additionally supplement the information or adjust care descriptions to provide extra details concerning a procedure or service provided to a patient.
  • Level II Modifiers: Also known as HCPCS Modifiers and these consist of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS – Centers for Medicare and Medicaid Services.

Obtaining the rightful revenue through your orthopedic requires detailed knowledge and the use of code modifiers wherever suitable and permissible. Modifiers are added to the main procedure code to indicate that the procedure has been altered by a distinct factor. Modifiers can increase or decrease reimbursement. They can also cause claims not to play properly or deny if used incorrectly or not used, when necessary. Some modifiers are for use by Ambulatory Surgical Centers only, some for physician practices, and some are for use by both provider types.

Here is a concise table representing the use of modifiers in orthopedic services:

Modifier

Procedure

Unit (ASC/P)

Condition

-50 Bilateral procedures Both
  • Used when an identical procedure is performed on both the right and left sides of the body.
  • Some payers prefer the use of the -50 modifier, and others require the use of the -RT anatomic modifier on one code and the -LT modifier on the other code.
  • Due to varied company policies, ASC facility should check with each payer to which they submit claims for their preferred method of billing bilateral procedures.
-51 Multiple procedures (P)
  • Use -51 when more than one procedure (excluding E&M codes) is performed on the same day during the same encounter by the same physician.
  • The exception to this guideline is if the CPT code is an add-on code, or if it is a –51 modifier-exempt.
-52 Reduced services
  • This modifier is used to indicate that a procedure was partially reduced or eliminated at the physician’s discretion.
-58 Staged or related procedure or service by the same physician during the postoperative period Both Use this modifier to indicate the performance of a procedure or service during the postoperative period that was:

1. Staged.

2. More extensive than the original procedure.

3. For therapy following a diagnostic surgical procedure.

-59 Distinct procedural service Both
  • Use this modifier to indicate the procedure or service was distinct or independent from other services performed on the same day, to identify procedures not normally reported together (due to CCI edits or “separate procedure” status in the CPT book), but which are appropriate under the circumstances or to represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury not normally encountered or performed on the same day by the same surgeon.
  • This modifier may override edits in the payer’s system, which would normally deny the code (i.e., unbundling, etc.), but under special circumstances, the modifier can be used to make the service payable — thus, the -59 modifier has a higher audit potential with Medicare and other payers.
-73 Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia (A)
  • This modifier is appended to the CPT code for the intended procedure(s) to indicate that a procedure was terminated due to medical complications after the patient had been prepared for surgery and taken to the OR, but before anesthesia was induced.
-74 Discontinued outpatient hospital/ASC procedure after the administration of anesthesia (A)
  • This modifier is appended to the CPT code for the intended procedure(s) to indicate that a procedure was terminated due to medical complications after anesthesia for the procedure was induced.
-76 Repeat procedure or service by the same physician Both
  • Use this modifier only if an identical procedure is being performed following the initial procedure.
-77 Repeat procedure or service by another physician Both
  • This modifier is used in a situation where a physician repeats a procedure that had previously been performed by another physician.
-78 Return to the OR for a related procedure during the postoperative period Both
  • This modifier will result in reduced reimbursement for the physician as the payment will reflect the surgery component only. However, failure to use this modifier, when necessary, will probably result in claim denial.
-79 Unrelated procedure or service by the same physician during the postoperative period Both
  • This modifier is to be used to indicate that an unrelated procedure was performed by the same physician during the postoperative period.
-RT & -LT Right Side and Left Side Both
  • If you bill a procedure that will be done bilaterally without the modifier for that side, when you bill the other side later, it may (needlessly) be denied as a duplicate claim, which will have to be appealed.
-TC Technical component Both
  • The –TC modifier reflects that the technical component only of an X-ray is being billed for by the ASC. This is billing for the taking of the X-ray or the use of fluoroscopy by the facility.
-FA
-F1
-F2
-F3 &
-F4-TA-T1-T2-T3-T4
Left hand, thumb

Left hand, second digit

Left hand, third digit

Left hand, fourth digit

Left hand, fifth digit

 

Left foot, the great toe

Left foot, second digit

Left foot, third digit

Left foot, fourth digit

Left foot, fifth digit

Both
  • Do not use –RT or –LT modifiers with these codes. Also, it is not necessary to use a -59 modifier with the digit modifiers unless you need to report more than one procedure on the same toe or finger when it is separately billable.
-F5-F6

-F7
-F8

-F9
-T5 -T6 -T7 -T8

-T9

Right hand, thumb

Right hand, second digit

Right hand, third digit

Right hand, fourth digit

Right hand, fifth digit

Right foot, the great toe

Right foot, the second toe

Right foot, third digit

Right foot, fourth digit

Right foot, fifth digit

 

 

-SG ASC facility service (A)
-GA Waiver of liability on file Both
-GY Statutorily excluded Both

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