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Gastroenterology Coding Alert

Consider Using -78 for Surgical Complications

Published on Sat Mar 12, 2005

Experts: Codes with the modifier pay about 80 percent of full value

When complications from an initial procedure cause a gastroenterologist to perform a follow-up procedure, the follow-up visit may be separately reportable.

How? If the follow-up procedure was serious enough that the gastroenterologist had to perform it in an operating room (OR), you may be able to get paid (partially) for it by using modifier -78 (Return to the operating room for a related procedure during the postoperative period), says Maggie Mac, a healthcare consultant with Pershing, Yoakley & Associates in Clearwater, Fla.

Take note: To use modifier -78 correctly, coders must be sure the gastroenterologist performed the second procedure at the proper place of service. Coders also need to know what types of services are part of the global package and what ones aren't or they might over-report on a claim.

Things Getting Complicated? Think -78

If your gastroenterologist treats a patient during the global period of an earlier procedure, keep your eyes peeled for modifier -78 possibilities, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Dallas, Ga.

"When a subsequent procedure is related to the first procedure, and requires the use of an operating room, you may report the related procedure with modifier -78," Parman says. 

Example: A patient has hemorrhoids, and the gastroenterologist cauterizes three internal hemorrhoids with a heater probe. The next day, the patient calls complaining of severe rectal pain. The gastroenterologist returns the patient to the operating room for a flexible sigmoidoscopy and discovers the patient has bleeding in the hemorrhoid-removal area. The gastroenterologist then uses a heater probe to stop the bleeding.

In this case, a patient was returned to the OR for a subsequent procedure directly related to the hemorrhoid removal during the global period. On the claim, you should:
 

  •  report 46934 (Destruction of hemorrhoids, any method; internal) for the hemorrhoid removal
     
  •  attach ICD-9 code 455.2 (Internal hemorrhoids with other complication) to 46934
     
  •  report 45334 (Sigmoidoscopy, flexible; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) for the sigmoidoscopy
     
  •  attach ICD-9 codes 569.42 (Anal or rectal pain) and 569.3 (Hemorrhage of rectum and anus) to 45334
     
  •  attach modifier -78 to 45334 to show that the procedure was a return to the OR to treat complications during the global period of an earlier procedure (the hemorrhoid removal).

    Warning: Modifier -78 is only for complications of the initial surgery that require a return to the OR. If your gastroenterologist can handle the complication without heading to the OR, the service is part of the initial surgery's global period.

    Expect Reduced Payout on Modifier -78 Codes
     
    When you file a claim with modifier -78 on a second procedure, you'll likely only collect a portion of the procedure fee, according to Mac. "Many carriers will reduce the modifier -78 payment and pay only for the procedure, minus the preoperative and postoperative percentages," she says.

    How much will a payer pay? Parman says that "although payer rules do vary, my experience with modifier -78 proves that payers will not reimburse higher for the complication than the total intraoperative portion of the allowed amount -approximately 80 percent, in most cases."

    However, that does not mean you should cut 20 percent out of your fee on the claim. When using modifier -78, report your normal amount and allow the carrier to adjust the reimbursement rate.

    Benefit: Letting the insurer reduce your payment slashes the chances of your fee being reduced twice.

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