Anesthesia Coding Alert

Question: Mr. Brown had endoscopic sinus surgery and then had to return to the operation theatre for control of a nose bleed on the same day. Anesthesiologists were different in both the cases. What modifier should be used for the second procedure?

Oregon Subscriber

Answer: In this scenario, you need to append 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). 

There are some carriers who prefer a -59 modifier (Distinct procedural service) over the -78, so verify the payer’s guidelines. 

Tip: You will have to use the diagnosis code 784.7 for the nose bleed to explain the reason there was a return to the OR on the same date.