Anesthesia Coding Alert

Question: A patient had a CABG procedure, then had to return to surgery later the same day because of complications. The same anesthesiologist handled both cases. The insurance company is denying our second claim with 00560 and modifier 78 as a duplicate claim. Someone suggested we resubmit with modifier 59 so it will be paid. What should we do?

Nebraska Subscriber

Answer: Compare the two operative reports to determine whether the surgeon performed the exact same procedure both times. Understanding what happened during each operative session will help you choose the correct modifier.

• Use modifier 76 (Repeat procedure or service by same physician) only if the surgeon performed the exact same procedure when they returned to the OR.
• Modifier 77 (Repeat procedure or service by another physician) doesn't apply in your case because the same anesthesiologist participated in both surgeries.
• Select modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) if the same anesthesiologist participates in both cases, but the surgeon doesn't perform exactly the same service both times. The second surgery is related to the first, but isn't a repeat procedure.

The 59 question: Some coders will lean toward modifier 59 (Distinct procedural service) for these cases, but it's not always the best choice. Modifier 59 represents two separate and distinct anesthesia services -- not the same anesthesia service provided twice.

Whichever modifier you choose, submit a paper claim with a cover letter and copies of the surgeon's and anesthesiologist's reports to help explain the situation to your payer.