Gastroenterology Coding Alert

Tip: Check for "return to OR" phrasing to support reporting.

You might be losing out on precious reimbursement if you're not appropriately applying modifier 78 when your gastroenterologist performs a follow-up service to address a complication arising after an initial surgical procedure. Keep these modifier 78 tips handy to accurately report complication procedures.

Don't Assume Modifier 78 is Not Allowed Within the Global Period

One common mistake that many coders make is to assume that any procedure done within the global period of an initial surgical procedure is not separately payable. If your gastroenterologist performs another procedure in the operating room or endoscopy suite that is related to the initial procedure, you should always see if there is the possibility of using the 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) to the procedure that is performed so that you can get separate payment for this procedure.

"When a procedure is related to the procedure done within the last 90 days, the 78 modifier should be the modifier of choice," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services -Health Revenue Assurance Associates, Plantation, Florida. The usage is however restricted to related procedures that carry 000, 010, 090, YYY or ZZZ global surgery indicator on MFSDB (Medicare Fee Schedule Data Base). "Almost all of the procedures performed by a gastroenterologist are from endoscopic families of codes and these all have zero day global periods ("000")," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA's CPT® Advisory Panel. "There are some codes dealing with haemorrhoid procedures that carry global intervals of 10 days."

Example: Your gastroenterologist performs an upper endoscopy with balloon dilation of a narrow peptic esophageal stricture to treat a patient with recurrent swallowing difficulty attributed to chronic reflux esophagitis. The dilation was uneventful with no bleeding and the patient felt well after the procedure with no pain. However, later in the day, the patient felt nauseated and vomited a large amount of blood. The patient was stabilized in the emergency room and returned to the endoscopy suite to address the complication.

In this case, you would code 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus[less than 30 mm diameter]) for the initial procedure and the procedure to address the complication with 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either theduodenum and/or jejunum as appropriate; with control of bleeding, any method) with the modifier 78 attached to it.

Reserve Modifier 78 for OR Procedures Only

Modifier 78 should be restricted to unplanned procedures that your gastroenterologist performed in an operating room or hospital endoscopy suite after the initial procedure. The room should be equipped for conducting the procedure performed by your gastroenterologist. "Modifier 78 is used when the procedure is in the OR or endoscopy suite and related to the original procedure," says Berman.

Note: In addition to the operating room, Medicare rules allow the procedure to be performed in an endoscopy suite, laser suite or a cardiac catheterization suite for modifier 78 to be used.

Repeat and Unrelated Procedures? Look to Other Modifiers

If the return to the operating room is for the repeat of the initial procedure, then it is not appropriate for you to use the modifier 78. In such a scenario, it would be safer for you to rely on the modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) for a repeat procedure that your gastroenterologist performed.

You would not use modifier 78 if your gastroenterologist is performing the same procedure as the initial procedure, and you have to use the same CPT® code for the second procedure. You can use the modifier 78 on the same CPT® code when the same code is suitable for use for services provided by your gastroenterologist in addressing the complications that arose from the initial procedure.

In a situation when your gastroenterologist is performing another procedure that has no correlation with the initial procedure that was performed, you should not use the modifier 78. Instead, you should use the modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the CPT® code of the second procedure. Note that the usage of the modifier 79 is not restricted for use in an OR setting, but can be used to describe office or bedside procedures.

Expect Reductions for Pre-, Post-op Care

As the usage of modifier 78 will not allow payments for pre- and post-operative care, you should always expect a payment reduction for the procedure code to which the modifier is appended. So you can expect to get paid between 65 to 80 percent of the full fee for the subsequent related procedure following the initial procedure. In contrast, you can expect a full payment for the procedure when a modifier 79 is attached to an unrelated procedure.