On behalf of the AOFAS, I want to welcome you to the seventh session of Crack the Code Practice Management and Coding Course Series. Today's session is the Surgical Global Period Modifiers in ICD-10 for Foot and Ankle. Today's presentations will be given by Jennifer Cabrera and Jennifer Bell. You can find their full biographies and disclosures in the program document posted in the chat box and in the On Demand Education Center. The series is funded by the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Paragon 28. I'd like to run through a few housekeeping items before we kick off the presentation. For technical difficulties, please try closing your browser and logging back on the same way you did the first time. Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit for this session by completing the evaluation and the CME claim form at the end of the full series. Tomorrow, you'll receive an email with the link to the evaluation in this specific session, and then at the end of the broadcast, you'll be able to evaluate and claim CME for the full course. This webinar is being recorded and will be available for on-demand viewing in the On Demand Education Center as a module within the course listing in approximately 24 hours. The recording will be available for one year. We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the broadcast, the faculty will reach out to you following the broadcast to respond to your question. I will now turn the program over. Thank you. Thank you, Julie. Thank you, Julie. I'd like to introduce my colleague, Jen Cabrera, and Jen will be manning the Q&A while we do this presentation, while I present the presentation here. So let me go ahead and share my screen with you. So today, we're going to be talking about modifiers. We're going to talk first about three very important office modifiers, modifiers 24, 25, and 57. Modifier 25 is a very hot topic right now, so we're going to spend a couple of minutes discussing that. Then we'll move into the surgical modifiers. And then on to a couple of ICD-10 tips and some codes to share with you there. So as we've done every week, this is our crew. I'm Jen Bell, so glad to be with you here today. Let's get started. All right, we want to make sure to have plenty of time in the end of the session to have some Q&A on these. So modifier 24, unrelated E&M during a postoperative period. So I wouldn't expect you to use this too much, but it definitely is available to you when a patient comes in during a global period with a new problem, or a new problem either in your global period or in your partner's global period. Okay? And of course, it is unrelated, right? So 24 means unrelated, so it would need a different diagnosis as expected, and it's unrelated. Here's our example for modifier 24. A patient complains of right ankle pain. The patient is new to you. You evaluate the patient. You diagnose a sprain of the ATFL. So there's that modifier 24 applied to the correct level of E&M service. This patient is a new patient, so it would be the 2-0. And then the level of service with that modifier 24, and of course, the appropriate diagnosis code there. All right. Modifier 57, decision for surgery. This is the code to be used only when it's the day before or the day of a major surgical procedure. Okay? So that 90-day global period, you'll want to append modifier 57 stating that this is the day that you decided to do the surgery, and this E&M should be paid separately outside of the global period. I will caution you here. I've had some orthos that will apply 57 whenever they schedule a surgery. They put it on there because they don't want to miss the opportunity and have the E&M deny. I caution you against that because modifier 57 is a monetary modifier. It's going to decrease that E&M service, the reimbursement. So only use it when it's the day before or the day of a surgery. Okay? What if I see, and here's a Q&A, we get these all the time, what if I see a patient and put her on the schedule next week, do I need modifier 57? No. Absolutely not. Can I append 57 to any E&M service? Yes. It's an E&M only modifier, but it can be applied to any E&M code, whether it's an ED visit, an admit, an office visit, any of the, any codes, consults. Here's an example. The physician's called to the ED to consult the patient who fractured the left distal tibia while rollerblading. After the evaluation, the patient's taken to the OR for an ORIF to fix the fracture. There's that modifier 57. This is a perfect example. You saw the patient, you assess the issue, then made the decision for surgery, then took the patient to the OR. That is the classic modifier 57 example. When not to use modifier 57, when it is not the day before or the day of surgery, okay? We've discussed that. And you don't use modifier 57 on minor procedures for zero or 10 day global periods. That's modifier 25. Actually, we're going to discuss modifier 25 here next, okay? So modifier 25, we all know this is the hot topic. It's been on the OIG's watch list for many years. And now in the past few years, commercial insurance companies have decided to A, get on the bandwagon, and B, make some interesting choices and changes regarding reimbursement when modifier 25 is used. So the definition is a significant separate E&M performed on the same day as a minor procedure, which would be those zero or 10 day global periods. So modifier 25 is the cousin to modifier 57. And modifier 57 is for E&Ms when a major surgery is being done, and 25 is for minor procedures or surgeries being done, okay? So lots of words on the screen. All of this information is in your book on pages eight and nine. That's where we're at right now. And I just want to call your attention to, I've got a couple of CPT assistants there in the book. So we are going to go over that second one, but just to reiterate, when modifier 25 can be used and should not be used, when a patient's condition requires a significant separately identifiable E&M, okay, above and beyond the normal pre-service and post-service for a procedure in the office, then you can bill a E&M visit with modifier 25, okay? So the E&M, let's see, different diagnoses, different diagnoses are not required, but it does need to be outside of the normal injection or whatever your minor procedure is there. Let's go on to this example. Now this is straight, this is that second in your book. This is actually top of the page. The second example that CPT assistant provided us in June of 2001, in fact. So this is quite an old example, but it still applies today. The patient comes in exhibiting pain in the elbow, proceeds to perform a joint injection as well as the service described in the E&M code. So the patient came in, saw the physician, then they decided that for the patient's issue that injection is needed, okay? So down here at the bottom with the star, the above mentioned symptoms prompted the patient to come in, okay? The patient did not visit with the physician with the intention of having a joint injection. So there it's telling us it wasn't previously scheduled, and the patient didn't come in and say, you know, I had an injection 10 years ago and I want an injection today, right? The physician assessed the patient, documented as such, and then made the decision to perform the procedure. That is an instance where modifier 25 should be used, and that's straight out of the CPT assistant. I do want to tell everyone about an article in the AAOS Now bulletin, and it's online, where Dr. Creavy, who is very well versed in coding and modifier 25 and how to use it correctly, it's just a really great article, and he lays it out for orthopedic surgeons as to when it is to be used and when it is not to be used. So just wanted to point that out, how to use modifier 25 correctly. What does Medicare say? Medicare says if a procedure, again, it lines up with CPT, if a procedure has a global period of zero to 10 days, in general, the E&M is part of that service. However, a significantly separate E&M for an unrelated decision, sorry, my clicker is not working well for me here, unrelated to the decision to perform surgery, okay, so there's your key, then a separately reportable E&M with modifier 25 is acceptable, okay? It does not require a second diagnosis, a separate diagnosis, it can be for the same diagnosis as long as it's not something that was decided before the patient comes in. So if you've got that patient that's in a series of injections and yet they come back in and you palpate and you talk to them for a minute, yeah, the pain's back, okay, let's go ahead and do another injection. That's not considered a separate E&M because they're already in that injection series, it's already been determined, they've been having their injections all along. If this is, say, a new patient or an established patient and it's a new condition, well, obviously you're going to assess that patient before you say, let's give them an injection. So you do your assessment and then decide that's what modifier 25 is for. And of course, with all these modifiers, we definitely have to have that documentation in place to support why it was necessary to perform that separate E&M service. So let's talk about modifier 50, when the same service is performed on both sides, the same anatomic site on both sides of the body or the contralateral versus the ipsilateral, both sides. In your book, I do want to point out on page 12, if you will, that first bullet, second line, just go ahead and mark through unilateral or that does not apply. So it's bilateral procedures, okay? So here's where we are, that top bullet, go ahead and it says defined as unilateral or bilateral. It's really only bilateral procedures, okay? So do not report a procedure with modifier 50 if the code is defined as bilateral, obviously that code has already been priced, it's the work RVU value has already been determined to include both sides, so you would not use modifier 50. For non-Medicare payers, the clearest reporting possible, which is really that first line item, you report the code without modifier 50 and the second line with modifier 50. That's the cleanest way, that's the way I always like to do it when possible, however, most of your MACs or Medicare carriers are going to say to put it on one line item and we're going to go over this here in a minute in another slide, one line item, units of one, but with modifier 50 on it, however, to duplicate, you should duplicate the price. So your coders and billers already know this, they should take care of that for you, but just so you know, for any surgeons that are on the call today, that's how we handle it. And I do apologize if you hear my dog barking in the background, she gets really excited about modifiers apparently. So that's what that's about. Do not use modifier 50 with any add-on codes. So that is definitely a no-no and they will be rejected for those add-on codes. Okay, here's an example, okay. For surgeon performs bilateral hip injections, and actually, forgive me, that should say foot injections. So here are the codes, 20605, and the second line would be 2060550 for that intermediate joint injection, okay. So that is what it would look like on a claim form, and of course, it would have the specific diagnosis for the primary osteoarthritis for the right foot and ankle and left foot and ankle. So let's look at what this looks like for Medicare. The top line is how Medicare wants it submitted. One line item with modifier 50 with one unit and two times the standard fee on that one line item. Most of your commercial payers accept either two or three. And for modifier 50, I will say that we don't have a, is modifier 50 better than RTLT when you're presenting with the same CPT code? It depends on the payer. There's not one or the other. It depends on what the payer wants so that they will pay that claim, okay. Modifier 51, multiple procedure rules. This is used when two or more procedures that are standalone, so two individual procedures that could be billed by themselves, are actually performed at the same surgical session where there's no potential for overlap, okay. The key here is modifier 51, again, is a monetary modifier, so it's going to decrease that value on the line item with modifier 51. So you'll want to put it on the lesser code, the lesser of the two codes for RBUs, which, of course, will in turn reflect in the reimbursement in your pricing. So the lesser valued code would have that modifier 51. So, of course, you would report the primary without modifier 51 and then the secondary on through however many codes you perform that day, modifier 51 where it does apply, okay. And the second service is subject to the payment reduction or the multiple payment reduction rule. And here's what that looks like. Medicare says we pay 100% for the first procedure and 50% from the second through the fifth procedure. And then from there, then they decide at sixth procedure on through, they decide their per MAC, they can decide how they handle that. So there is a reduction value in that. So obviously, you want to put that 51 on that lesser procedure, lesser valued procedure. Now, this is a case, and I'm actually in Texas, and Novitas does not like 51 or unless it's changed recently, Medicare, Novitas does not like 51. So they instruct people not to use it. So you'll want to check your MAC, your Medicare provider, because some do not want 51. Here's an example. A patient is seen in the office for a right closed, non-displaced transverse tibial shaft fracture, and a right non-displaced fracture of the second metatarsal. Of course, we've got the two diagnosis codes there that would apply. And if you'll notice, look at the RVU values. And so this is coded correctly, 27750 would be your primary without modifier 51, and it has the most work RVU values. And then of course that secondary code 28470 with modifier 51 where the work RVU value is 6.63. So that's just an example there of modifier 51. Now let's talk about modifier 59. And right now we are on page 14. So distinct procedural service. So modifier 59 says we're doing two procedures but they can be confusing, they can be confused, and there is potential service overlap. And payers could say that kick the claim out for duplication. So we wanna be very careful and use our 59 modifiers where needed, okay? Secondary codes, again, before we get further into this, secondary codes with modifier 59, again, subject to that multiple procedure reduction of 100% for the first line item and then 50% for the second through the fifth line items with modifier 59 on it, okay? So very important to only use it when you need to use it. Again, I've had some providers that say, well, we put it on everything so that we don't have any claim rejections. Well, you might not have claim rejections, however, you are going to have decreased reimbursement on that. So what is distinct? Why do we need a modifier 59? If there is a different session on the same day, different procedure or surgery, different anatomic site, separate incision, separate lesion, separate injury, different area, extensive injury, et cetera. And again, don't forget that multiple procedure reduction does apply, so use it sparingly. Here's a modifier 59 example, okay? And I believe, yeah. So this is a little bit different than what's in your book. So you might want to take note. The surgeon performs a right ankle injection with ultrasound guidance and a right elbow injection without ultrasound guidance. What's common? Both are intermediate joints, right? And so we've got the potential for, again, on the same side of the body. So there is potential for the, ensure to get confused and have overlap. So the first line item, we'd build 20606 with ultrasound, okay? To that ankle, the injection to the ankle with ultrasound is worth a little bit more. So we would put that as our primary. And then the secondary code 20605 with a 59 modifier because without ultrasound, it would be the lesser of the two. Now, one thing to remember here is Medicare does, if we had an ankle on one side of the body and an elbow on the other, Medicare does consider RT and LT more specific in this case than modifier 59. This is different than what we talked about with modifier 50. Modifier 50, they prefer 50, but 59, they do prefer right and left when it applies. It doesn't apply here, but when it does apply on the contralateral sides, then you would want to use that instead. CMS, again, says only to use modifier 59 if an edit exists between the two, right? The NCCI edits or those CCI edits we used to call them, same thing. And of course, LT and RT more specific, okay? Modifier 76, repeat procedure, when to use. When a service is repeated by the same physician, okay? There is another modifier here. Just, you can write this down in your book and look it up later, but it is when a service is repeated by another physician in your practice and it's under their global period. That's modifier 77. So we get some questions about that as well. So don't confuse the two. 76 is usually what we see most often, but 77 can occur if you're having to go in after, or maybe your partner's out for the day or on vacation, and then you have to take someone back to the OR. That is very possible. So they did provide us a modifier for that, but they act in the same way. So I want to make sure and point that out here. And of course, this is applied when a CPT code, Max, and this is something a few years ago, Max came back and said, we want 76. Let's look at this next slide, and I will show you what I'm talking about when it's more than one anatomic occasion. All right. So documentation tips for modifier 76. And again, CAHABA, you'll see that first bullet there, CAHABA actually no longer exists, but back in 2013 and 14, they were part of this that released instruction to use modifier 76 instead of 59 when it's the exact same CPT code reported more than once during the same session. So that's just a little caveat there for modifier 76 instead of 59 for WPS and Noridian. You'll want to check with your MAC carrier for your region to find out if they have the same ruling. Other carriers that we know of and Novitas included, to my knowledge, still has this in place, instructed to report using units instead. Okay. Use only if there is not a more appropriate modifier, so 76 would be only if there's not another one that's more applicable, and do not append 76 to an E&M. Again, all of these modifiers that we've discussed after modifier 25 are surgical only modifiers, not for E&M services. Here's an example for modifier 76. A physician performs an ORF of the patient's third and fourth metatarsal fractures on the left foot. Okay. So that first line CPT says that first or second column, I should say, but the first coding column, 28485 on the first one, and 2848559 on the second procedure. CMS MAC that wants 76, obviously say put 76 on that second procedure. And then of course the third MAC, that's the one line item, and you put it on one line with two units of service. Okay. And with two units of service, of course it will automatically duplicate the price and increase it appropriately. Okay. So let's not forget our toe modifiers. Just wanted to make sure we discuss this just a moment. So here's a scenario when, and again, just like I said, if not a more appropriate modifier, this might be the case. Maybe the surgeon was on a toe and there is a T modifier that is more appropriate. CPT and CMS method. One is the physician performs open treatment of a displaced second and third proximal phalanx fractures. Okay. On the patient's left hand, there's the appropriate ICD-10 code. So it would be 28124-T1 and T2. Okay. That's the first method. CPT method number two. Okay. 28124, 2812459. Okay. Some payers may want a 59 as well, or instead of the T codes, CMS MAC method two. There it is with the T code. And then the 76 and the T code. Okay. And then of course, MAC number three, as always one line item with two units of service and the pricing of course will duplicate itself when those units are added in. And of course, private payers, you know, we just never know. They always, you might call them or your staff might call them and say, they'll say we follow NCCI guidelines. We follow Medicare guidelines, but I would suggest if you do run into this situation, at least the first few times, I would give them a call and make sure that they follow all of CMS guidelines because a lot of times, as you know, they'll follow the NCCI edits, but then they have their own guidelines for modifiers and how to report services. So let's go all the way back to 2015 and talk about the modifier 59 subsets. I personally has nothing to do with anything. I just didn't have much success back in 2015 when we were submitting claims with these modifiers, they didn't seem to catch on as well as I would like. However, a lot of practices are using them and doing so successfully. So you can still use these XE for separate encounter, XS separate structure, XP for practitioner, and then the XU for an unusual non-overlapping service. All right, so Medler Matters said again, again, January the 1st, 2015, providers may continue to use modifier 51 or you can use the new modifiers in the same manner, whichever you prefer. They have not varied from that. They have not deviated from that. So it's up to you what you want to use, potato, patata, that's dealer's choice, if you will. We don't have many of those in coding. So I say, let's take it where we can get it. So modifier 59 decision tree. In your book on page, let's see here, on page 18 is the full decision tree. You might find this useful for some of your new coders and billers just to give them an idea of modifier 59 versus 51. But we just included that there, that in your book at that particular place, just so that you would have it and maybe pass it on if you needed to, to those newer and less experienced folks. All right, now, so we talked about office modifiers. We talked about surgical modifiers. Now we're gonna talk about surgical modifiers that can be used or that are specifically designated for that global surgical period. When you're in a global surgical period with a patient. So there's still only surgical modifiers, not ENM modifiers, but specifically developed for the global period. Good old modifier 58, which is staged procedure. And it's used when a subsequent procedure was planned or staged from an original procedure or is more extensive than the first procedure. And of course, cast changes, we just put this up here, class changes, cast changes during a global period would need a modifier 58 as well for subsequent casting. The initial cast is included, but casting after the initial is always separately billable. Again, this applies if you operate out of a place of service 11 and you have the expense or the cost of those casting supplies and that employee. Obviously in a hospital setting, then you would not bill for anything that the hospital is paying for casting wise. But other than that, they are separately billable outside of that initial cast. Documentation tips. For modifier 58, a new postoperative period begins. Okay, so that's, you know, it is what it is. The clock starts over with that new post-op period. However, the good part is with that new post-op period, 100% of your standard allowable should be paid for modifier 58 services in that staged procedure, okay? And of course, you wanna make sure to dictate in that indications paragraph. And you wanna do that as well on the initial surgery because for staged procedures, put something in there that lets the payer know this is a staged procedure. We'll be doing a second part of it later on as a separate session. And that is definitely very helpful on appeal. We've seen quite a bit of success on appeal for that. So be sure and indicate that it was staged, why it was staged, what you had to do differently, okay? Modifier 58 example. And I believe on this one, I have two examples, yes. A 25-year-old patient had a closed metatarsal fracture reduced two weeks ago. Patient returns complaining of pain. X-ray reveals loss of reduction. And now you've got to take the patient to the OR for an ORIF, an application of a post-op splint. And here we're just coding for the procedure only to show you where that modifier 58 would apply. So we would build that out as a 28485 with the modifier 58 because this requires taking that patient back to the OR for a more extensive procedure, okay? Now here's another example. Patient in example two returns for an application of the long leg cast during the local period. Everything's going great, fracture's healing well, but of course that cast, you need to recoup for that cast payment. So you'd build your post-op visit and always, always, always put in that code for those post-op visits. And here's my little quick soapbox on that because Medicare is tracking how many post-op visits you perform during a global period. That's where they get the information and send that information to the RUC. And that's where they review, when they review surgical codes, they go back and look, well, how many post-op visits did this patient have nationwide? How many post-op visits did most orthos see this patient for during, for this specific CPT? So it's very important to make sure, even though it's a non-payable code, it's very important to go ahead and code that out. And then of course, your 58 modifier on that cast application, and then the cast supplies as well, which would not need that modifier 58. Modifier 78, unplanned return to the OR for related procedures during the global period. So this is for complications during that global period that require a return trip to the OR, okay? Different than modifier 58. A lot of people get 58 and 78 mixed up because 78 is a staged procedure and you stage and related, and then 78 is related to the original procedure. So different concept though. 78 is for complications, not for a staged procedure. And again, with modifier 78, this is a good part. The global period does not restart, so that's good. Reimbursement will be reduced, however. So if you notice, if the global period restarts, then generally the modifier will not reduce payment. However, if the global period does not restart, then generally the reimbursement will be reduced with that modifier. So 78 is a monetary modifier. It's gonna decrease the value, okay? And it can only be used in a facility place of service, ASC, inpatient, outpatient surgery, not the office, okay? And Medicare only pays for complications requiring a return trip to an approved suite. I mean, the ICU is an exception, but Medicare doesn't pay for admits or E&Ms with the complication, but they do pay for a complication that requires a return trip to the OR, just to clarify. Here's the example. A patient underwent Achilles rupture repair two weeks ago. And now they're following up. The repair is intact, but it appears the patient has an infection and they're taking the patient back to the OR for an INT. Staff group B was cultured. So here we've got taking that patient back with a complication of the original surgery, during the global period would be the 10180 for that IND for complex post-op wound infection with a modifier 78. And of course it shows both the infection and the bacterial growth on this claim. Modifier 79, so unrelated procedure during a post-op period. Okay, so this is a new completely unrelated procedure. It's used for both minor and major procedures, global days. So both 10 and 90 day global days for modifier 79. It is a cousin to the modifier 24. So it is to surgery what modifier 24 is to E&Ms. It's saying we've got something new and different that we're having to take the patient to the OR for that is not related to the global period that they are currently in. So a new post-operative period does begin, but it is reimbursed at 100%. So there we go. Even though a new post-operative period begins, so now you've got to restart that 10 or 90 day period, you are, it is considered 100% reimbursable at the standard allowable. So that is very good. And here's our example of 79. Patients seen five weeks during a global period at five weeks for right knee arthroplasty. And this is the only one that I couldn't actually find a code for. The patient's previously been treated for right shoulder arthritis and returns to the office for an injection. So this would be on that shoulder. We're doing an intermediate joint injection on the shoulder and it would be 2060579. So this one doesn't specifically relate to ankle, foot and ankle, but it does, it holds true. So just the example holds true with modifier 79. They're completely unrelated. Patient brought back in during a global period. Here is one of the most common questions that we get. Again, it's not foot and ankle, but this is the question and the answer to it. It relates the same to foot and ankle as it does for all other orthopedic situations. So the physicians want to report a 2061079 when they perform a joint injection for pain during the global period. Is it acceptable? No, pain management joint injections during a global period for any of the joints in the body are not separately billable, okay? It's considered typical follow-up care. Modifier 22. All right, modifier 22. Services performed increased procedural service. So this is an increase, it's not the norm, it's increased intensity, time, effort, technical difficulty of the procedure, physical and mental effort required, severity of the patient's condition or their comorbidities or their habitus. Some patients are going to be more difficult to operate on than others. The key is to document, document, document. Document the amount of time that it took extra that it would normally, than it normally takes you to perform the procedure. And of course, document any reason that you feel that the modifier 22 would be appropriate. Here's an example, revision decompression of a right median nerve at the carpal tunnel. 28285 of the modifier 22, okay? So forgive me, I do not believe that this slide, yes. All right, so here's an example. We'll just look at the bottom in the matrix 28285-22, correction of hammer toe, okay? Dictate the findings paragraph. So like I said, document, document, document. Why is modifier 22 justified? Increase your fee, this is very important and your coders and billers should be aware of this. Increase your fee 20 to 30%, okay? And you may need to file the claim electronically and then submit the operative report after the fact. But some want you, they have their own way of doing it. They want you to submit certain paperwork. Your coders and billers will know what each carrier wants but you definitely want to monitor the reimbursement. On these, I will tell you it does automatically kick it out. It does not go into a six week review. So it does take longer to get paid for these but persistence pays off. And of course you never use modifier 22 on E&M services or x-rays or add-on codes, anything like that, okay? So your explanation to payer, and this is just an example of what we say would be part of that paragraph, okay? To explain the procedure performed was more technically demanding, increased physician work intensity than the standard procedure. Here are the key factors that included one, two, three and list them as applicable, of course. I estimate the above issues increase the value of the standard procedure by 25 to 30%. You put your value in there and then make sure that your coders and billers make sure that they know to follow through and increase that value accordingly. So how do you know how much time it takes for each procedure? Well, CMS has provided us a complete listing of all of the CPT codes and the amount of time it takes and the amount of time that they have allotted to the pre, intra and post operative care. And here is the website and I believe it is in your book as well under modifier 22 on page 23 where you can go and or have your coders, billers go and take a look. You might wanna pull your most recent or your most, not just most recent but your most often used codes and take a look at it just so that you can be familiar with the amount of time that they normally allot for a procedure. But it actually is very informative to go and look for these. So let's talk about the last two modifiers and true to form, we're gonna have some time here for questions. Modifier 52 is added when it's a reduced service, okay? Less than the work defined by the CPT code. Don't append it to EMENM, clearly document what you did perform, the portion of the procedure that was performed and submit your fees in full or according to payer policy. But if they tell you, you do not have to reduce them, we recommend not reducing the fees for a 52 because the payer will be more than happy to reduce them for you. And if you reduce them and then the payer reduces them again, that's not gonna be to your benefit. So we say, submit fees in full and of course, monitor reimbursement. Here's an example, a minimal partial osteotomy angular correction of the first toe on the left foot. That would be a 2831052TA, okay? So again, they're using the TA modifier on there as well as that 52. Modifier 53, this is for a discontinued procedure, okay? And as we say here, discontinued prior to the initiation of the procedure itself. So the tip here is if anesthesia is induced before the procedure is discontinued, then that's when you'd want to use that modifier 53, okay? And of course, it's used when the physician likes to terminate a surgical procedure because there is a threat to the wellbeing of the patient. Okay, so that's modifier 53. So let's turn over in your books. To page 25. And actually this information, I just wrote this down so I'd make sure and discuss it with everybody. These are tips from the actual chapter, the musculoskeletal chapter in the ICD-10 book. Excuse me, chronic or recurrent conditions are coded from chapter 13 or what we call the M codes, okay? And acute injuries should be coded from the injury chapter, chapter 19. These are general guidelines from the S and T codes. And this is a little bit surprising for some people when you read, and you can read this for yourself in the guidelines in the front of the ICD-10 book under the chapter guidelines. For the seventh digit, A is to be used for the initial encounter with the patient and when the patient is still in active treatment. And it does cover fractures as well as other issues. So as long as they're in active treatment, you should still use A. D is for when the active treatment is completed, okay? D is for those subsequent encounters after treatment is completed. And then of course, S is for sequelae or complications that result as a direct result of a condition, okay? So here are some frequently used, here's those M codes, right? The osteoarthritis codes for ankle and foot. And we've just provided, you see these in your book here. Again, pointing out that those M codes are conditions. Not primary injuries and frequently used more condition codes. I will say that G57, that is gonna be for your tarsal tunnel and the lesion of the plantar nerve. Those are actually nervous codes out of the Gs. So those are gonna be, those are the only ones that don't fall under the generalized category here. But if you'll notice all of the others are the M codes to fall under condition codes. And then your sprains are the S codes. So that's under chapter 19 for those injury codes. And they all require either an A, a D or an S for the sprains and more sprains and strains. And here's a question that we get asked quite frequently. Which code is used for sprain of the ATFL ligament or the talocalcaneal ligament? Having trouble speaking today, my goodness. S93.49, okay. So this one is one case where, and of course, the right or left for that six digit is one case where you would need to use an other code. Generally, we don't like other codes, but sometimes we do have to use them. And of course the seventh digit would be needed as well. Either A, D or S on that. And here are the strains. Again, S codes for injuries. Lacerations, more S codes, okay. And of course you wanna code also any open wound that is in conjunction. This is why we're giving you these here. With any sprain, strain or laceration, any of those you'd want to code separately for them. And that is actually all I had for slides. So I'm going to ask if, let's see where, Jen, see. Hi there, everybody. Thanks for joining us. Jen, we just have a couple of questions. Would you like me to read them for you? Yes, I'm going to open them up here as well. Let's see, okay, perfect. So there's a couple of questions about the workbook and I believe Julie can answer that, but it is available through the AOFAS website where you registered for the course. Typically they upload it to the chat as well. If that's not done, you will be able to get it from the website. In terms of questions regarding the content here, thank you so much, Jen Bell. Our first question is that when mentioning the use of modifier 59, you did mention using it sparingly. However, our question is in the example of the injection where you gave an injection to the ankle and the elbow, if you didn't use modifier 59, would the payer just automatically deny the claim? It's possible. It is possible. Hopefully they would look at the records, but again, being hopeful with carriers is not always the best way to go, but they would probably deny it. And then you would have to go back and use a modifier 59. For sure, use modifier 59 when there's an NCCI edit. And the reason I said use it sparingly is simply because it is a monetary modifier. So it's automatically gonna reduce the payment on the secondary or tertiary on down, but it will not reduce obviously on the first line item without modifier 59, but it will. And again, some, I can't tell you how many people I've come across audits and they use 59 even on the first line item. It's like, no, absolutely don't use that because you're just kind of shooting yourself in the foot. All right. Then our next question actually from our same attendee is during the discussion of modifier 58, can you clarify again if you can bill for the actual first cast application? Right. First cast application is always included, not separately billable. But once you bring that patient back into your office for more casting during the global period, then that is billable with a modifier 58. Perfect. That's all the questions that we have in the chat here. Anyone else? I'd like to, I'd like to see my audience here. My goodness. Okay. Well, we don't seem to have any further questions here. Sorry, clarification. Let's see. The Q codes or the closed reduction code. So the cast application code and the Q codes go hand in hand. So the Q codes are the, oh, Jen's gonna be typing an answer here, but I'll say it out loud while she types. The Q codes are for the supplies. So you do not need a modifier 58 on that. And of course you're already in the global period for that closed reduction. So you would not build a closed reduction code again with a 58, just the cast supply. That's when you would bill for the, go back here. I was gonna try to be fancy and go back. That's when you would bill for the cast application cast application with modifier 58 Q code, no modifier 58. And I believe that's what you were asking. So the Q codes do not require it. And you're already in a global period for the closed reduction. Now, if you have to go back and re-reduce. So if you have to take the patient back to the OR and re-reduce, it would depend on the circumstances. I would assume that, yeah, that might be a, depends on the timing. We'd have to see the situation depending on if it was the same day, if there are lots of different things that it would depend on but you would not need to report the closed reduction code again, just report the Q code and the casting itself. Anyone else? Thank you, Dr. Theron, hopefully that, that helped. And again, the workbook is, should be available. If you don't find it, please let the. The workbook should be in the chat box. If not, we can make it available. We can make it available. All right. And I think that is all the questions we have. Julie, did you have anything else? Nope, that's it. Thank you all so much. We've appreciated this time over the seven weeks. I know Jen as well, we've appreciated our time with you. Thank you so much. Have a great rest of your day. Thank you. Bye-bye.

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