What CPT Modifiers Are Used with Code 21825 for Open Sternum Fracture Treatment?

Correct Modifiers for CPT Code 21825 - Open Treatment of Sternum Fracture with or Without Skeletal Fixation

This article will discuss the correct use of CPT code 21825 and its associated modifiers for accurate medical coding in the field of surgery, particularly when dealing with open treatment of a sternum fracture. Medical coders should be aware of these details to ensure proper billing and reimbursement. The codes for this article are provided by AMA for use by trained medical coders with a license! Using them without a valid license is against US laws!

What is CPT code 21825?

CPT code 21825 represents the "Open Treatment of Sternum Fracture with or without Skeletal Fixation." The procedure involves surgically opening the fracture site, realigning the fractured bone, and possibly fixing the bone in place using a stabilization device. Medical coding professionals in the surgical specialty play a vital role in understanding and applying the correct CPT code for the level of surgical care provided in treating this particular injury.

When is CPT code 21825 used?

The doctor will often have to access the sternum through a surgical incision to address the break. They then will ensure the broken pieces are properly aligned, and potentially place a stabilizing structure, like screws, wires, or plates. The wound then is irrigated and closed. Here are some situations where this CPT code could be used:

• The patient experienced a trauma to the sternum area, resulting in a fracture.
• The doctor chooses open surgery rather than other non-surgical options like a closed procedure. This often occurs when the bones are out of alignment.
• A stabilizing method is employed to facilitate healing. This might involve devices like wires or screws.

When is CPT code 21825 NOT used?

• For closed treatment of a sternum fracture, a different code would be applied (CPT code 21820).
• If the fracture is to the sternoclavicular joint (between the sternum and collar bone), a different code would be used (CPT codes 23520-23532).
• In the case of injections (either at the fracture site or trigger point), another code should be used (CPT code 20550).

What modifiers are used with CPT Code 21825?

CPT code 21825 can have a variety of modifiers associated with it. These modifiers are added to the primary code to provide additional information and clarify the specific circumstances of the surgical procedure performed. Here's a closer look at some common modifiers, accompanied by scenarios to explain their usage and reasoning:

Modifier 51: Multiple Procedures

Let’s say the patient with the sternum fracture sustained another unrelated fracture, such as a broken ankle, during the same encounter. When coding for both procedures, modifier 51 would be attached to CPT code 21825 for the open sternum fracture repair and the other fracture's CPT code to reflect that both procedures occurred during the same surgical session. In these situations, an experienced medical coding specialist uses these modifiers and other coding procedures to correctly report procedures according to AMA coding protocols.

Modifier 54: Surgical Care Only

Consider this: The patient, having sustained a sternum fracture, presented to the emergency room for initial treatment. This situation raises questions regarding the provider’s involvement. Was the provider who handled the emergency room care solely responsible for the initial surgical management, or will they be responsible for the ongoing post-operative care? If the provider treated the fracture in the emergency room but will not be providing follow-up care, you would use modifier 54 for the open sternum fracture CPT code (21825). The 90-day global period is often involved. This helps clarify billing and ensures proper compensation for the care given in the emergency room context. The physician will be reimbursed for the surgical care performed.

Modifier 56: Preoperative Management Only

Here is another real-life example: A surgeon may have seen the patient several times to assess the injury, order imaging studies, and make a detailed plan for surgery. Let's assume the surgeon then decided they would not personally handle the surgical repair and referred the patient to another physician for that specific procedure. The original surgeon's work would only include the preoperative evaluations. Modifier 56, indicating preoperative management only, would be attached to CPT code 21825 in this instance.

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

This modifier comes into play when the physician completes another, directly connected procedure related to the original sternum fracture surgery after the initial procedure. If, for example, the patient required removal of fixation devices later during the healing process, this additional procedure would be reported using modifier 58 with the new CPT code that reflects the removal of the device. It would indicate that the second procedure was connected to the original surgery and happened within the global surgical period.

Modifier 76: Repeat Procedure or Service by the Same Physician or Other Qualified Health Care Professional

Here’s the scenario: The patient unfortunately has an unsuccessful first surgery for the sternum fracture. It did not heal appropriately. The patient had to undergo a second, subsequent surgery to re-fixate the sternum, which was carried out by the original doctor. This situation involves a repeat procedure by the same surgeon, necessitating the application of modifier 76 with the CPT code 21825. The modifier 76 would apply to the original CPT code to clarify that a repeat surgical procedure occurred, allowing for accurate reimbursement of this specific event. The physician should only use these modifier if there were complications following the first surgery that require them to repeat the process to attempt successful healing.

Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional

Consider this: The original surgeon who performed the open sternum fracture procedure was unavailable to perform a repeat surgery. Due to the lack of success in the first surgery, the patient required a repeat operation, but another surgeon handled this secondary procedure. This particular case would necessitate the addition of modifier 77, indicating that the repeat procedure was carried out by a different physician or healthcare provider.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

This modifier is applied when the original provider must return the patient to the operating room, unplanned and due to complications during the initial surgical treatment. During the original open sternum fracture surgery, perhaps a device or sutures caused unexpected issues, leading to the physician immediately addressing them by performing an extra procedure.

Modifier 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Here’s a hypothetical case: The same physician performing the original sternum fracture surgery later decides to perform a procedure that is totally unrelated to the first surgical procedure, but the second procedure was done in the same operating room or on the same day. The unrelated procedure might be due to a different medical concern or discovered in the initial surgical procedure. The application of modifier 79 to the second unrelated CPT code allows for accurate billing, making it clear that this procedure was not part of the initial surgical procedure for the sternum.

Modifier 80: Assistant Surgeon

Let’s look at a situation where another doctor was involved during the surgery. The surgeon was assisted by another doctor who was not the primary operator on the procedure. If a different provider worked as an assistant, providing additional hands and expertise during the surgery, then modifier 80 would be used, but only with the surgeon’s billing, which represents the work the surgeon completed. It is added to the surgical CPT code and would be reflected as a separate line item, providing more detail and transparency on billing practices.

Modifier 81: Minimum Assistant Surgeon

This modifier, 81, specifically refers to an assistant surgeon who primarily aids the surgeon, performing duties that do not encompass a significant level of complexity. These activities can include retracting tissues, offering general surgical support, or maintaining patient stability during the surgery. Modifier 81 is applied to the surgeon’s code in the same way as modifier 80. It clarifies the specific role and duties performed by the assistant, potentially affecting the total cost of the surgery.

Modifier 82: Assistant Surgeon (When Qualified Resident Surgeon Not Available)

The application of modifier 82 refers to a unique circumstance where a resident surgeon typically would have assisted the primary surgeon but is not available for the procedure. An alternative provider, perhaps a fellow physician, may then step in to assist the surgeon. This scenario would be captured using modifier 82.

Modifier 99: Multiple Modifiers

If the surgeon needed to apply multiple modifiers to CPT code 21825 for an open sternum fracture, then modifier 99 can be applied to indicate that more than one modifier was used in this scenario. This helps streamline the coding process and provides additional clarity regarding the complex factors involved.

Additional Considerations for Using CPT Code 21825:

Beyond understanding the core elements of CPT code 21825 and the modifiers used with it, it's crucial to keep in mind the specific nuances of its application and reporting requirements. The AMA, which owns and governs the CPT code system, emphasizes the need to use updated versions. Not only will this provide more up-to-date information but also ensure that coding is compliant with current regulations, avoiding legal ramifications! Medical coding in the surgical field requires a deep knowledge of coding rules and current code revisions to ensure accuracy, prevent any discrepancies with billing, and comply with legal standards. Some critical considerations include:

• Global Surgical Period: When dealing with procedures like this, remember that there is a global surgical period often associated with CPT codes. This period represents the time from just before the surgery begins until the post-surgical care concludes (this timeframe varies but is typically 90 days). Understanding and applying the concepts of the global surgical period help clarify when it is and is not appropriate to bill for associated services and procedures, and if you use a different CPT code or add a modifier, such as Modifier 54!
• Documentation Requirements: Comprehensive and accurate documentation is vital. The documentation must support the CPT codes and modifiers. The surgeon’s notes need to detail every aspect of the procedure and the reasons for applying any modifier. If the surgeon refers the patient for additional treatment, this information needs to be present in the documentation and reflected in the coding.
• Coding Compliance: The AMA requires that the codes and descriptions be used only as they are presented in their books, including any guidelines. Always refer to the current, authorized CPT code manual when coding. There are severe legal ramifications for misusing or violating CPT guidelines and proper use of the AMA’s published codes. The penalties can range from fines and legal action to revocation of a coder’s certification and license! The need for accurate coding ensures that healthcare professionals receive fair compensation for the services provided and that the patients have an accurate record of their medical procedures.

Examples: How the Information is Applied

Let’s explore some realistic use cases.

Scenario 1:

The patient arrives in the Emergency Room due to a direct blow to the sternum causing a fracture. The provider performs an open reduction and internal fixation of the sternum with two stabilizing screws. After providing post-operative care, the doctor also provides post-surgical care for the 90-day global period. In this case, CPT code 21825 would be used along with the appropriate modifiers for the specific aspects of the service.

• The use of modifiers would depend on whether the patient will need follow-up services within the global surgical period.
• Since the provider provided both surgical care and post-operative follow-up, there is no need to append modifier 54 "Surgical Care Only" to the code. The medical coder could choose to append a different modifier to the code if appropriate to the patient's specific case and according to AMA requirements.
• Modifier 76 “Repeat Procedure” should not be used because it does not apply.
• If there are any other applicable modifiers related to the complexity of the procedure or other events during the global surgical period, these should be added and clearly documented for auditing and reimbursement purposes.

Scenario 2:

The patient arrives in the hospital emergency room after experiencing chest trauma. After assessing the situation, the provider elects to perform open reduction and internal fixation of a fracture of the sternum using one stabilizing plate. However, the provider informs the patient they are not the one who will handle any post-surgical care for this condition. They will refer the patient to a specialist for ongoing post-operative treatment. In this scenario, CPT code 21825 would be used again, and the modifiers will vary based on this scenario's particular factors.

• Given the ER provider is not handling the post-surgical follow-up, Modifier 54 would be added to CPT code 21825.
• If there are other applicable modifiers, including, for example, modifier 76 or 77, these should also be added to code 21825. They must be justified based on the case documentation.

Scenario 3:

The patient has been undergoing treatment from a surgeon for several weeks, with this same surgeon also performing the open surgery with internal fixation of the sternum fracture. In a later encounter, the physician found that the internal fixation was failing. In this specific scenario, the surgeon performs a revision of the original procedure using different stabilizing screws for additional strength and to enhance healing. The doctor also continues to oversee post-operative care following the second surgery. In this scenario, you would continue using code 21825 for both procedures, with adjustments depending on whether or not this is considered a repeat procedure, a new procedure, or related procedure within the global surgical period:

• Since the second procedure involved additional services after the initial procedure and occurred within the global period, Modifier 58 would be applied to code 21825 for the second procedure.
• If a resident performed any services in addition to the physician, then another modifier should be added to ensure accurate billing and appropriate reimbursement.

---

Conclusion: Accurate Billing and Proper Use of CPT Codes

By following AMA's guidelines and accurately applying CPT codes 21825, you ensure the proper billing and reimbursement for the care provided. The details we've discussed regarding modifier applications are critical. If you use outdated codes, fail to comply with AMA regulations, or neglect to include appropriate modifiers or supporting documentation, this can result in penalties. By staying informed on CPT code updates, their guidelines, and proper modifiers, you can maintain the highest standard of compliance and coding accuracy for every case.