Modifiers, Surgical Package, and E/M Services in Orthopaedic Practice
The surgical package
The global surgical package includes preoperative evaluation and planning, the procedure, and postoperative care for the global period (0, 10, or 90 days). Fracture care and most major orthopaedic procedures carry a 90-day global. Included services are writing orders, the first cast or splint in fracture care, routine follow-up, and treatment of complications. A return to the operating room for a related complication may be separately reported with modifier 78.
Key modifiers
24 is an unrelated E/M during a global period. 25 is a significant, separately identifiable E/M on the same day as a procedure. 57 is the decision for surgery for a major procedure. 58 is a planned or staged procedure during the global. 78 is an unplanned return to the operating room for a related complication. 79 is an unrelated procedure during the global. 50 is bilateral, 51 is multiple procedures, and 59 or XS, XE, XP, XU identifies a distinct service. 22 is increased complexity, 52 is reduced service, and 76 and 77 are repeat procedures.
Traps
- Adding 25 to an E/M that is really the preoperative evaluation.
- Using 78 for a planned second stage, which is 58.
- Reporting bilateral when the payer requires two lines with LT and RT.
- Using 59 to bypass an edit with a modifier indicator of 0.
Rule of thumb: 58 planned, 78 unplanned related, 79 unrelated; 24 applies to E/M only.
Worked example: A patient in the 90-day global for a total knee arthroplasty falls and fractures the contralateral wrist, requiring new fracture care. Report the fracture care with modifier 79.