# Modifier 78 or 79?



## nyyankees (Dec 4, 2009)

I have an interesting question - My Dr (Dr A) sees a pt injured on a motorcycle. Dr B performs ORIF of tibial plateau. Dr A, my guy, performs menisectomy and MCL open repair.

Pt returns to Dr A for removal of external fixator and I&D from the ORIF. The surgeries are from 1 injury. Yet my Dr did not perform ORIF but since he saw pt already and removal is from the same injury should I bill out with 78 modifier?

I don't want to use 79 modifier unless I'm 100% certain. Thanks as I think this one could be tricky.


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## kjstearns (Dec 7, 2009)

Was the removal planned? What about a -58?


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## nyyankees (Dec 7, 2009)

The original procedure was done by a different Dr which would rule-out 58. I guess my question is since it was the same accident would that rule-out the 79 modifier?


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## RGALVEZ (Dec 7, 2009)

I'm assuming that Dr A and Dr B are NOT in the same practice and/or do NOT have the same tax ID. On that assumtion, if your Dr did an I&D on Dr. B's procedure, then you would bill with modifier 55 since your Dr. is assuming the "Post Operative care only". If they are under the same tax ID, then modifier 78 would be the modifier needed here. Hope this doesn't had to the confusion.


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## nyyankees (Dec 7, 2009)

RGALVEZ said:


> I'm assuming that Dr A and Dr B are NOT in the same practice and/or do NOT have the same tax ID. On that assumtion, if your Dr did an I&D on Dr. B's procedure, then you would bill with modifier 55 since your Dr. is assuming the "Post Operative care only". If they are under the same tax ID, then modifier 78 would be the modifier needed here. Hope this doesn't had to the confusion.



What is the reimbursement % of modifier 55? I would think modifier 79 would be better since it was "unrelated" to my Dr's first surgery? This is a little confusing.


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## kjstearns (Dec 7, 2009)

Sorry, I didn't realize that the doctors were not in the same group. Personally, I would go with a -79 in this case since it is not related to the surgery that your doctor performed.


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## mitchellde (Dec 7, 2009)

I agree with the 55 regardless of the reimbursement it is the right modifier.  You are taking over the postoperative portion of a procedure performed by a different surgeon.


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## nyyankees (Dec 8, 2009)

mitchellde said:


> I agree with the 55 regardless of the reimbursement it is the right modifier.  You are taking over the postoperative portion of a procedure performed by a different surgeon.



I don't code on reimbursement but I need to know since my Dr is going to want to know. It seems to me that I'm getting responses for 55 and 79. I knew this was going to be a tough one.


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## jdemar (Dec 8, 2009)

When your physician takes over the care of the original surgery in the global time, it should be a -55 modifier....we see many trauma cases in our practice that the original accident happened in another state and when the patient comes home they come to our practice.  You have to be certain to bill the exact CPT code the original surgeon used.  The 55 modifier tells the carrier that you want part of that original reimbursement.


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## nyyankees (Dec 8, 2009)

Ok...Thanks. Looks like 55 is the correct way to code this procedure. I'm glad I asked because I was looking at either 78 or 79. Better safe than sorry!


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## FTessaBartels (Dec 9, 2009)

*Return to OR?*

Ortho is NOT my area of expertise, but ... 

If the removal of hardware and I&D were done under anesthesia in an operating room then you are NOT just taking over postoperative care from Dr B.  If you returned the patient to the OR I would use the 79 modifier as it is unrelated to the previous surgery Dr A performed (and therefore NOT covered in the postoperative period for Dr A's procedure).

On the other hand ... If this was *done in the office suite*, I would *not* code for it at all.  Why? Because Dr A is already seeing the patient in a postoperative global period for the menisectomy and MCL open repair.   (Unless the injuries were to different legs ... e.g. Dr A on right leg, Dr B on left leg ... then I'd code the same CPT as Dr B did with a -55.)

Gosh, this IS complicated!

F Tessa Bartels, CPC, CEMC


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## nyyankees (Dec 9, 2009)

FTessaBartels said:


> Ortho is NOT my area of expertise, but ...
> 
> If the removal of hardware and I&D were done under anesthesia in an operating room then you are NOT just taking over postoperative care from Dr B.  If you returned the patient to the OR I would use the 79 modifier as it is unrelated to the previous surgery Dr A performed (and therefore NOT covered in the postoperative period for Dr A's procedure).
> 
> ...



Same leg, Multiple injuries from a single motorcycle accident. Dr B performed a repair on 1 aspect of the injury (ORIF) while my doc, Dr A, performed a surgery (menisectomy, MCL repair) on another injury/part of the same knee/leg. Dr A then took the patient back to the OR for removal/debridement of Dr B's ORIF procedure.

My Dr already plans (Staged as he noted in op-report #2) for more repairs/surgeries. The thing is that this patient had multiple injuries that needed to be addresses from a single accident. Just want to make sure I use correct modifier. The research I've done on modifier 55 is, as it seems to me, that a Dr took over the post-op services and that you should report the original surgical code with the 55 modifier. That would be fine if it was just office visits but my Dr took him back to the OR to complete/rectify the other Dr's surgery...Very confusing


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## FTessaBartels (Dec 10, 2009)

*Back to the OR is NOT post-op care*

Taking the patient back to the OR is *NOT* post-op care and those procedures are separately reported. So forget about the -55 modifier for now.

Also you have never answered the question of whether these two doctors are in the *same practice and of the same specialty*. If they *ARE*, they are considered the same doctor, so use the *-78 modifier*.  If they are *different practice or different specialty use -79 modifier*.

Also, if they are in the same practice/same specialty then you cannot report Dr B's procedure w/ a 55 modifier for Dr A.  Regardless, I would not code ANY office visits ... not even when Dr A is looking at original wounds from surgery done by Dr B. I do not think there is sufficient extra work being done in these evaluations over and above what Dr A would do for his OWN postoperative care of the patient. (Think of it this way ... If Dr A had done all the procedures himself, he wouldn't code two postoperative visits for one encounter ... would he?)

As Dr A has now indicated that the patient will need to go back to the OR for a series of procedures, you'll be using the -58 modifier for each return to OR for these "staged or related" procedures. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## mitchellde (Dec 10, 2009)

I agree if this was a return to an OR then it would be either 78 or 79, from the original submission it looked like an office encounter.


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## nyyankees (Dec 11, 2009)

FTessaBartels said:


> Taking the patient back to the OR is *NOT* post-op care and those procedures are separately reported. So forget about the -55 modifier for now.
> 
> Also you have never answered the question of whether these two doctors are in the *same practice and of the same specialty*. If they *ARE*, they are considered the same doctor, so use the *-78 modifier*.  If they are *different practice or different specialty use -79 modifier*.
> 
> ...



Yes different practices.


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## nyyankees (Dec 11, 2009)

mitchellde said:


> I agree if this was a return to an OR then it would be either 78 or 79, from the original submission it looked like an office encounter.



No it was for surgery not office visit.


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## mbort (Dec 14, 2009)

I'm with Tessa on this one---79 modifier would be appropriate for a return to the OR for an unrelated (to the 1st procedure).


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## armedical (Dec 14, 2009)

Modifier 55 Post Opertative Management Only; Reimbursement 70% most payers; 80% Florida Medicare


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