Anesthesia Coding Alert

A fine line distinguishes the usage of modifiers -78 (return to the operating room for a related procedure during the postoperative period), -79 (unrelated procedure or service by the same physician during the postoperative period) and -58 (staged or related procedure or service by the same physician during the postoperative period), despite what seem to be straightforward definitions. The modifiers are normally used by surgeons rather than anesthesia providers, but sometimes apply for pain-management. Coding professionals should keep the definitions of "related," "unrelated" and "staged" procedures in mind when deciding which modifier to append.
 
Coding for a Related Procedure

"The key issue with using modifier -78 is being sure that the 'take-back' procedure is somehow related to the initial procedure," says Cecelia McWhorter, BA, CPC, a coder with the physician-billing agency Comp One Services Ltd. in Oklahoma City. "Common examples from a surgical perspective could include a patient returning to surgery to take care of postoperative bleeding after aortic-valve replacement or cardiac tamponade or for an anastomosis leak following a colectomy," McWhorter notes.
 
B.J. Johnson, CPC, MPC, a member of the National Advisory Board of the American Academy of Professional Coders and a coder in Loma Linda, Calif., explains how two common examples would be coded from an anesthesia perspective:
 
1. An anesthesiologist places an intrathecal catheter for a patient (62350, implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy). Three hours later, the patient develops a hematoma. Follow-up treatment of the patient would be coded as 62350-78 with a diagnosis of 996.1 (mechanical complication of other vascular device, implant, and graft).
 
2. The anesthesiologist places a spinal-nerve stimulator (63650, percutaneous implantation of neurostimulator electrode array, epidural). A hematoma develops several hours later. Code follow-up treatment as 63650-78.

Before using modifier -78, coders should check whether the follow-up procedure is part of a staged procedure instead of a separate, related procedure.

Coding for Unrelated Procedures

Procedures using modifier -79 must be unrelated to the original procedure. Unrelated procedures usually involve a different surgery and site, and often have a different diagnosis as justification. Two anesthesia or pain-management scenarios that commonly use modifier
-79 include:
 
1. An anesthesiologist places an intrathecal catheter for a patient's pain management (62350). Three weeks later, the patient returns to the physician for a joint injection to relieve pain. The joint injection would be coded as 20605* (arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) and appended with modifier -79.
 
2. A patient seeing a pain specialist for a steroid epidural for chronic back and leg pain mentions after the epidural has been injected that he has neck pain. A trigger point is identified and injected. The physician has performed two separate, unrelated procedures. The trigger-point injection would be coded with 20550* (injection, tendon sheath, ligament, trigger points or ganglion cyst) and appended with modifier -79 to indicate that this injection was unrelated to the first.

Staged procedures using modifier -58 are intended to be completed in two or more sessions, whereas procedures using modifier -78 are expected to be completed in a single session. Common examples of surgically staged procedures include two or three procedures for cleft-lip repair, staged excision of a lesion or staged closure of a wound. Johnson says that many coders add modifier -58 to the primary procedure's code and the following procedure's to document they are related procedures.
 

For example, a neurostimulator electrode is implanted for a patient (63650), but the generator is not implanted at this time. Instead, the electrodes are attached to an external generator for a trial period. If the stimulator helps the patient, a permanent generator will be placed in two weeks. The second procedure would be coded 63685 (incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) and appended with modifier -58. The operative report should show the staged procedure of removing electrodes from the temporary external generator with planned implantation of the permanent generator. Johnson says some coders may include modifier -58 with the initial procedure code (63650) as well, with the intent of permanently implanting the generator later.
 
Keeping the Modifiers Straight

Because modifier -79 describes unrelated procedures, it is more straightforward than -78 or -58. When distinguishing between these two, McWhorter and Johnson say, intent during the planning procedures determines whether modifier -78 or -58 is appropriate for later procedures.
 
Johnson explains, "If the surgery is planned and is staged, modifier -58 is used. Cases involving modifier -78 almost always involve a complication from the first surgery that requires a second procedure to fix the problem."