Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.
After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt for modifier 79 abuse. Implement our expert tips below to keep your 79 claims clean.
Obey Global Package Model
The starting point for clean modifier 79 claims is not breaching the global surgical billing concept. Once you understand the global package rules, you’ll know when you have an exception that warrants an additional claim with an appropriate modifier.
Know what’s included: The global package includes the preoperative visit the day before surgery, intraoperative services, postsurgical complications, and postoperative visits during the global period. It also includes post-surgical pain management services by the surgeon, and miscellaneous services such as dressing changes, suture removal, staples, etc., according to Donna Pisani, provider outreach and education consultant with National Government Services (NGS) during a global surgery conference call. NGS is a Medicare payer in 25 states.
Choose 79 for Distinct Procedure During Global Period
If your surgeon performs a service during the global period that the “package” doesn’t include, you can bill separately for the additional procedure — but you’ll have to use a modifier.
Key to 79: You’ll know that 79 is the correct modifier if the second procedure is for an unrelated condition during the global period of the first surgery. In other words, if the same surgeon must perform a separate, unrelated procedure for an unexpected medical condition during theglobal period of a previous procedure, you should append modifier 79 to the subsequent procedural code(s).
Tip: “If the second procedure takes place on a different body part, 79 is usually the correct modifier,” says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio.
Another clue that you should use 79 is if the surgeon links a second procedure to a totally different diagnosis and does not mention a “complication” or that the second procedure is staged or related to the first, according to Lamm.
Example: The patient is in the global period for a partial mastectomy (19301, Mastectomy, partial [e.g.,lumpectomy, tylectomy, quadrantectomy, segmentectomy]). During that time, the patient has an appendectomy (such as 44970, Laparoscopy, surgical, appendectomy) because of acute appendicitis. You should append modifier 79 tothe appendectomy code.
Scrutinize Your 79 Claims — Before Your Contractor Does
Thanks to abusive practices of some providers who used modifier 79 to bypass surgical bundling rules, the Office of Inspector General (OIG) “has asked all contractors to look at codes with modifier 79,” Pisani says.
Loophole: Although CMS established pre-payment edits to detect when providers unbundle services from the global surgical package, services billed with modifier 79 were excluded from those pre-payment edits. That’s why CMS has instructed contractors to “strengthen program safeguards” against fraudulent 79 claims.
“Be aware if you’re using modifier 79 that you’re using it appropriately, and your records reflect the documentation,” Pisani notes.
Resource: To read the CMS instruction on modifier 79 scrutiny, go here.
Distinguish Other Global Period Modifiers: Unrelated conditions aren’t the only reason your surgeon might perform a separate procedure during a global surgical period. If the second procedure is not unrelated to the initial surgery, you’ll have to turn to modifiers other than 79.
• Identify planned or staged: Call on modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) when the surgeon performs a secondary surgery during the post-op period of another surgery and the subsequent procedure was planned or staged, Pisani notes.
• Distinguish related but not planned: Modifier 78 (Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postop period) applies to the service when the physician has to unexpectedly return the patientto the operating room (OR) for a related procedure during the postoperative period, Pisani says.
Remember OR restriction: Medicare will only pay for treating a complication during the surgical global period if treatment requires a return to the operating room. Modifiers 58 and 78 do not apply if the Medicare beneficiary does not return to the OR.
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