Don’t let ‘unplanned’ lead to ‘unpaid.’
The next time a patient takes an extra trip to the operating room, don’t let the added service throw your coding off track. Keep these tips in mind to know when to assign modifier 78 – or something else.
Check for Surprise Versus Planned
Two modifiers pertain to follow-up trips to the OR, but knowing the basic difference helps you choose the right one:
• Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) represents an expected return to the OR. This could be because the original surgery normally is performed during multiple sessions or the follow-up is more extensive than the original procedure. “The patient’s condition dictates the additional service or the service was planned prior to the original surgery,” explains Linda Parks, office manager for Herrin Family Medicine in Lilburn, Ga. You can also report modifier 58 for non-OR sessions, such as planned therapy following surgery.
• Modifier 78 (Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period) “would be used when a complication arises after surgery and the patient has to be returned to the OR,” Parks says. The complications, rather than the patient’s condition, call for a follow-up procedure related to the original surgery. Modifier 78 is the payer’s tip-off that the new procedure was related to the original surgery.
Consider these two examples from Kathy Nelson, CPC, a coder with Fletcher Allen Health Care in Burlington, Vt.:
• Your surgeon sees a patient in the emergency room who has multiple trauma injuries. He reduces a fracture and applies an external fixation system with the intention of taking the patient to the operating room later for more definitive treatment. You would apply modifier 58 to the codes for initial and follow-up treatment.
• A patient develops a postoperative wound infection related to the primary procedure and requires a return to the OR for irrigation and drainage of the infection. You’ll append modifier 78 in this case because the follow-up procedure was unplanned.
Easy tips: If you still have trouble distinguishing modifiers 58 and 78, check for these clues:
• Watch for surprises. An unplanned – but related — surgery leads to modifier 78; an expected follow-up equals modifier 58.
• The patient does not have to return to the OR for modifier 58 to apply. The patient must return to the OR before you can consider modifier 78.
Don’t Automatically Jump to Modifiers
What happens if your physician provides follow-up care within the global period that doesn’t require another OR visit? Chances are you won’t need a modifier at all.
Here’s why: Medicare considers all postoperative complications “related” to the initial surgery unless the patient must return to the operating room. Uncomplicated follow-ups don’t merit their own codes.
Example: Mrs. Jones develops a minor infection at the surgical wound site a few days after her surgery. She comes for an office visit, and your physician cleans and dresses the wound. Because the follow-up was so simple, you won’t code for it – the office visit and care are part of the original procedure’s global surgical package. “We would bill 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure), as this would be considered normal postoperative care,” Nolin says.
Filing tip: “In our office, we bill these visits with a $0.00 dollar amount and do not file to the carrier,” Parks says. “It’s for record-keeping only.”
Expect Lower Pay With 78
When a claim qualifies for modifier 78, get ready to receive lower pay for your physician’s extra service.
Why: Procedures billed with modifier 78 include only the “intraoperative” portion of the service, not the pre- and postoperative care. Payers generally reimburse at 65 to 80 percent of the full fee schedule value when you append modifier 78, depending on how the fee schedule allocates the presurgical, intraoperative, and postsurgical portions of the procedure’s reimbursement.
Remember: Reporting a second procedure with modifier 78 doesn’t affect the global period. Because the surgeon is only paid the intraoperative allowance, the original procedure’s global period remains intact.
Example: If a complication occurs 20 days into a 90-day global period, only 70 global days remain after the return to the operating room.
Look for Chances to Use Modifier 79
Whereas modifier 78 applies to follow-up procedures related to the first surgery, you’ll turn to modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) for unrelated procedures.
Example: A patient sustains multiple injuries (other than broken bones) in an automobile accident. The surgeon takes the patient to the OR to fix a tibial shaft fracture. He returns the patient to the OR to repair a distal radius fracture several days later once the patient is medically stable. You can append modifier 79 to the distal radius procedure to indicate it was not related to the earlier tibial shaft fracture treatment.
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