Pertinent Insights On Coding For Wound Care

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Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   Dr. Aung frequently uses modifier -57 when she decides to perform surgery for new or established patients who present with an acute abscess or a worsening abscess or ulceration. This modifier would also cover the attendant workup as well as the pre-op history and physical to schedule the procedure. Dr. Aung may either schedule the procedure for the same day or sometime in the next few days.

   Modifier -25 covers a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, according to Dr. Goldsmith. Dr. Poggio says one uses the -25 modifier when the procedure has a 0 or 10 day global period. Dr. Goldsmith says this modifier is applicable for an established patient who makes an appointment for an abscess on the tip of the fifth toe on the left foot with local erythema and swelling, not to mention pain. He says the doctor would bill CPT 10060 for the incision and drainage of the abscess, and an E&M service with a -25 modifier appended for the initial workup of the problem.

   Dr. Poggio cautions that each procedure has a certain amount of E&M built into the procedure fee allowance. When the evaluation and management is beyond that time period, he says one can append the E&M with one of those modifiers. If one is only providing wound care, Dr. Poggio says the modifier may not be appropriate. On the other hand, he notes if one is prescribing or changing existing antibiotic prescriptions, ordering or reviewing labs or diagnostic studies, or instituting new wound care protocols, then an E&M service may be payable in addition to the wound care codes.

Q:

What are examples of surgical code modifiers, such as -59 (distinct procedural services)?

A:

Modifier -59 indicates that one is operating on two or more separate locations, incisions or body parts, according to Dr. Suzuki. One example he cites is if one is applying skin substitutes to foot and ankle wounds simultaneously, the codes would be 15271 and 15275 (-59).

   Dr. Goldsmith considers a hypothetical patient presenting to the office with two ingrown nails, one on the lateral border of the left hallux and the other on the medial border of the right hallux. Conservative treatment occurred previously for the left hallux ingrown nail and the physician decided to perform a matrixectomy. He notes the coding would be CPT 11750-TA and CPT 11730-59-T5. As Dr. Goldsmith explains, the -59 modifier tells the payer’s computers that the nail avulsion is distinct and not related to the matrixectomy.

   “One would think that the ‘T’ anatomical modifiers would alone say the same thing but unfortunately, a number of payer software programs ignore ‘T’ modifiers,” explains Dr. Goldsmith.

   As for other modifiers, Dr. Aung says -22 is for increased procedure service, covering substantial additional work along with the reason for added services.
If the procedure code description does not exclude its use, then Dr. Aung says one should use -50 (bilateral procedure) to document the same procedure performed during the same surgical session on the contralateral limb.

   Dr. Aung notes that one would use modifiers -54, -55 and -56 to reflect that one physician provides only surgical care, postoperative management and/or pre-operative management services while another physician provides the other services that are bundled in the surgical case fee.

   Dr. Aung says modifier -76 covers a repeat procedure by the same physician while modifier -77 is for a repeat procedure by another physician.

   Dr. Goldsmith says modifier -78 concerns an unplanned return to the operating/procedure room by the same physician following the initial procedure for a related procedure during the postoperative period. Dr. Aung says an example would be a patient who develops an infection or hardware becomes unstable after the original procedure.

   Modifier -79 is for an unrelated procedure or service by the same physician during the postoperative period, notes Dr. Goldsmith. Dr. Aung gives the hypothetical example of a patient who underwent a bunionectomy and fell, and presented with a metatarsal fracture, which requires surgery.

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