need help with repeat surgery

[dekenn]

Hello All,
Need some input on how to appeal this so it gets paid.
Patient had right ankle fracture, operated on 11-27-19, CPT code 27822. It was paid by Medicare.
On 12-17-19, it was determined that she had a loss of reduction and needed to have a repeat procedure.
Surgery was on 12-20-19. I submitted it to Medicare, same procedure, CPT 27822, because that's what the doctor performed, with modifier 76, repeat procedure same physician, with the same fracture diagnosis and the diagnosis for displacement of internal fixation device. Medicare denied it as global. I appealed online with an explanation as to why she needed the repeat surgery, and they denied it again. I then filed a request with an independent contractor and included pre-op office notes and the operative report, again explaining the need for the second surgery. They also denied stating "the guidelines for global surgery state that a visit furnished within the global period of a surgical procedure may be covered separately if the E/M service provided was not associated with the surgery." They then state that "A review of the documentation submitted does not support the service was separate and distinct service."

They state that I can still appeal to an Administrative Law Judge, but wanted some feedback first. Am I right in thinking that this should be a covered service? Did I bill incorrectly? Is there something I'm missing?
From reading the response, I almost feel like they didn't even read my appeal, they keep referencing E&M services, which I never mentioned!!!

I know this is long and involved, but any help would be GREATLY appreciated!
Thanks in advance!!

[kristin]

I think the problem is the wrong modifier was used. It should have been a 78, for unplanned return to operating room by same physician. That is what fits the scenario you describe.

If you look at the description of 76 modifier, and when it should and should not be used, you will see why it was the wrong modifier:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00092327

Specifically the part that says "adding to a surgical code" under the Inappropriate Uses area. They then go on to list 3 modifiers that can be used for surgical codes, and the 78 is one of them. Also, the 76 is generally used for repeat procedures or services performed all in the same DAY.

Also, I am not sure what exact fracture diagnosis code you used that was the same for both claims, but my guess is that the seventh letter probably should have been different for the second surgery.

[dekenn]

Thanks Kristin!
So do you think it would be better to appeal it to the administrative law judge or submit a corrected claim?

Also, I did submit with the same diagnosis for both surgeries: S82.851A. I added the diagnosis for displacement internal fixation device for the second one. My thought was that it was still active treatment for the fracture.

Thanks so much for any advice on how to get this processed and paid. 

[kristin]

Submit a corrected claim, for sure, I think you are still within timely filing for that. As for the dx, I think you need a different 7th character. While the treatment is still "active", the dx has to reflect where the PATIENT is at healing wise, and not the treatment. Look at the characters available for the dx, and I think you will see that there is a better one than A. Perhaps G, H, or J?

[dekenn]

Hi Kristin, Thanks so much for your help so far, I was out of the office last week and need to get this done this week! I can't submit a corrected claim on the website because I already appealed, should I mail in the paper claim? Can I do this even though I've appealed the original claim? Or should I do the appeal to the Administrative Law Judge with the information that the claim was submitted incorrectly?
Thanks so much for your help, I've never run into a repeat surgery before!
Deb

[kristin]

If the claim was originally submitted electronically, I would simply correct it, and resend it electronically. This is how my MAC wants it done.  See what happens, and come back and let us know. You can't submit it on paper, unless you have a waiver to submit claims on paper from Medicare.

[dekenn]

Hi Kristin,
I looked at the seventh characters, since this wasn't an open fracture to begin with, I don't believe I can use H or J. And because the fracture shifted, with displacement of internal fixation devices, wouldn't I use character K (nonunion) or P( malunion)?
Thanks

[dekenn]

Thank you so much for your help Kristin! I resubmitted the claim with the correct modifier and it processed and was paid. Thanks again!

[kristin]

YAY! I love a happy ending!