Gastroenterology Coding Alert

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

How? If the follow-up procedure was serious enough that the gastroenterologist had to perform it in an operating room (OR) or endoscopic suite (hospital or ASC), 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 M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

Stay alert: On Jan. 1, this modifier's definition changes to "Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period." This CPT 2008 revision clarifies its use.

Take note: To use modifier 78 correctly in 2007 or 2008, you must be sure your gastroenterologist performed the second procedure at the proper place of service. You need to know which types of services are part of the global package and which ones aren't or you might over-report on a claim. You also need to know the global period for the initial procedure. For instance, surgical procedures like hemorrhoid treatments can have global periods of 10 to as long as 90 days. However, all endoscopy procedures have a global period of one day, ending at midnight on the day of the procedure.

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-founder of Coding Strategies Inc. in Powder Springs, 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 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 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.

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 more 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 from your claim's fee. 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.