Cardiology Coding Alert

Modifiers:

Solve Surgery Modifier Challenges With This Expert Advice

Published on Wed May 26, 2021

Hint: Modifier 78 requires a trip back to OR.

Modifiers are an essential part of filing your claims correctly and keeping your deserved reimbursement. In fact, Cheryl Hanson, from the Part B Medicare Provider Outreach and Education team at Noridian, said in a recent webinar, “There might be sometimes when a modifier is used and a claim is paid, but then we may need to recover that payment because the modifier was misused.”

So, when it comes to modifiers, especially reimbursement modifiers, you must make sure you use them when applicable or your payer can deny your claim.

Read on to learn about some common surgery-related modifiers and how to append them correctly on your cardiology claims.

Editor’s note: All of the modifiers discussed below are reimbursement modifiers, which as the name suggests, determine your reimbursement. You may also encounter informational modifiers such as RT (Right side) and LT (Left side), which indicate information such as “who” and “where.” You should always list reimbursement modifiers first on your claim and informational modifiers second, according to Hanson.

Only Use Modifier 53 Under Specific Circumstances

One surgery modifier you may see in your cardiology practice is modifier 53 (Discontinued procedure). You may use modifier 53 under certain circumstances when your physician elects to terminate a surgical/diagnostic procedure either due to extenuating circumstances or if the procedure threatens the wellbeing of the patient, Hanson said.

Some examples of why your physician might have to discontinue a procedure include the following:

Adverse reaction to anesthesia
Obstructed airway
Cardiac arrest
Hemorrhaging
Severe hypertension or hypotension

Caution: You should not use modifier 53 to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or the surgical preparation in the operating suite, according to the CPT^® guidelines.

Documentation requirements: Submitting modifier 53 alone does not provide your payer with enough information to know how to correctly reimburse the provider. So, make sure you submit supporting documentation for appending modifier 53. The documentation must state that the physician actually started the procedure, why it was medically necessary for him to discontinue the procedure, and what percentage of the procedure he did perform.

Example: Your cardiologist attempts to upgrade an already-implanted cardiac venous system to a biventricular device by adding a left ventricular lead. During the procedure, the patient started experiencing respiratory distress. Your cardiologist chose to terminate the procedure to protect the patient’s health. Your cardiologist documents that he completed 50 percent of the procedure.

You should report 33224 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)) and append modifier 53 to indicate that the procedure was discontinued because of health reasons. You will also submit the proper documentation supporting the use of modifier 53.

Append Modifier 58 for Staged Procedures

You should report modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) for procedures that are staged or a related procedure or service by the same physician during the post-op period.

Documentation requirements: When you use modifier 58, the documentation should indicate that the procedure or service performed during the post-op period was:

Planned or anticipated (staged);
More extensive than the original procedure; or
For therapy following a surgical procedure

Caution: You should not use modifier 58 would not be used when a code descriptor says, “one or more visits or sessions,” according to Hanson.

Example: The cardiologist performs a removal of a dual chamber pacemaker generator (code 33233, Removal of permanent pacemaker pulse generator only) due to infection. You should report 33233 on your claim. The cardiologist plans to insert the pacemaker pulse generator at a later date when the infection has been resolved.

Two weeks later, after the infection has cleared up, the cardiologist performs the planned pacemaker pulse generator insertion (33213, Insertion of pacemaker pulse generator only; with existing dual leads). You should report 33213-58 on your claim.

Modifier 78 Requires Trip Back to OR

If your physician performs an unplanned return to the operating/procedure room following the initial procedure for a related procedure during the post-op period, you should report 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).

Caution: You should only use modifier 78 on surgery codes, and you cannot this modifier if the procedure could be done at the patient’s bedside or in the physician’s office, Hanson said.

Documentation: The chart record should show that the two surgeries were related and the subsequent required a return to the operating room (OR).

Three questions: You should ask yourself three questions when considering whether it’s appropriate to append modifier 78.

Question 1: Is the subsequent procedure related to the initial surgery? You should only append modifier 78 if your surgeon undertook the subsequent surgery due to complications from an initial surgery.

Question 2: Does the procedure fall within a global period? To correctly append modifier 78, the subsequent surgery must occur during the 90-day global period of the initial surgery.

Question 3: Did the physician perform the procedure in the OR? To correctly append modifier 78, the subsequent surgery requires a return trip to the OR.

Example: Your cardiologist determines that the patient’s right ventricular lead of the dual chamber ICD became dislodged during the global period of the original surgery. Your cardiologist takes the patient back to the OR to disconnect the lead from the generator, reposition the lead, and reconnect it. He restores pacing. For this service, you should report 33215-78 (Repositioning of previously implanted transvenous pacemaker or implantable defibrillator [right atrial or right ventricular] electrode).