Key to use of modifier is if it is a stand-alone procedure
By Jeri L. Harris
Several questions have been asked about when debridement codes are used with fracture codes and what modifiers, if any, should be used.
When using CPT codes 11010, 11011 and 11012 for debridement of foreign material associated with open fracture(s) and/or dislocation(s), none of these CPT codes include the treatment of the fracture. The definitions of fracture care have been modified to more accurately reflect current orthopaedic procedural treatments, such as "closed treatment", "open treatment" and "percutaneous skeletal fixation."
Since the type of fracture (e.g., open, compound, closed) does not have any coding correlation with the type of treatment (e.g., closed, open, or percutaneous) provided, CPT recognizes that open fractures sometimes requires extra treatment to clean out debris from the fracture site. The CPT codes 11010, 11011 or 11012 can be used for either open or closed treatment of fracture(s) and/or dislocation(s). The treatment of the fracture and/or dislocation is the key to properly code an open or closed fracture. The following is a coding example:
A patient presents to the emergency room with an open, non-displaced, great toe fracture of the left foot. The orthopaedic surgeon determines that the fracture needs debridement to clean the fracture debris and fracture site prior to wound repair and closure. The orthopaedic surgeon debrides the tissue, muscle and exposed bone, determines the fracture to be non-displaced, then repairs the muscle, fascia, subcutaneous tissue and wound closure.
The fracture was open, but the treatment was closed, as the surgeon did not surgically open or expose the fracture to the external environment. The debridement was tissue, muscle and bone associated to an open fracture. Therefore, the correct coding for the above scenario would be 28490-LT and 11012-51. The debridement is not considered an "add-on code" as CPT has specific guidelines regarding "add-on codes."
According to CPT guidelines, add-on codes are exempt from multiple procedure concepts if they are commonly carried out in addition to the primary procedure performed. All add-on codes in CPT are readily identified by the specific descriptor, such as "each additional" or "(List separately in addition to primary procedure)."
Basically that means if a surgeon performs a procedure that can stand-alone (or by itself), a -51 modifier would need to be attached to any subsequent procedures. However, if it is a procedure that would or could never be performed alone, then that CPT code is exempt from the multiple surgery concepts.
Coding controversy: How to correctly bill for injection drugs (intra-articular steroids). The HCPCS book contains Medicare's National Level II Codes, such as injection drugs, durable medical equipment, etc., Depo-Medrol is described under methylpredisolone acetate. The dosage is 20-mg (J1020), 40-mg (J1030), or 80-mg (J1040). This seems easy to code, but herein lies the problem: even though HCFA recognizes the injection drug, each individual state Medicare carriers have different guidelines. Individual Medicare carriers have ideas as to what they will pay and how they want it billed. If an individual Medicare carrier has its own HCPCS Level III code, that code must be used in order to get your claim paid.
For instance: A physician injects a patient with 40-mg of Depo-Medrol. The correct coding would be J1030. If your Medicare carrier instructs a provider to use J1020 (20 mg), unit 2, then the provider has no recourse other than to code the services as per the instructions by the individual Medicare carrier.
I would advise the provider to get any instruction or advice in writing from the insurance carrier to safeguard the provider from any future problems.
Coding controversy: Can I bill for casts and strapping if I bill office visits, and not bill for global fracture care? The CPT guidelines states that codes 29000-29799 are to be used for:
If a physician applies the initial cast, splint or strapping also assumes all the subsequent care for the fracture, dislocation or injury, he/she cannot use CPT codes 29000-29799, as it is included in the treatment of fracture and/or dislocation codes
Restorative treatment or procedure rendered by another physician following the application of the initial cast/strapping may be reported with a treatment of fracture and/or dislocation code.
If a cast/strapping/splint is provided as an initial service by the physician rendering the initial care only, the use of casting, strapping or splinting (29000-29799) and/or supply code (99070) can be billed in addition to an evaluation and management code, as appropriate, if the following rules and guidelines apply:
Jeri L. Harris, CPC, CPC-H works for a large multispecialty orthopaedic
practice in Charleston, S.C. She is serving her second year on
the National Advisory Board for the American Academy of Procedural
Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.