Gastroenterology Coding Alert

Question: My gastroenterologist placed a gastrostomy tube. Then, the tube leaked eight days later so the physician sent the patient back to the operating room (OR) and then changed the tube. Should I append modifier 78 or 58 to the tube change code (43760)?

Arizona Subscriber

Answer: You don't need a modifier in this case. Code 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) has zero global days so there is no global period. Therefore, you do not need modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) or modifier 78 (Unplanned return to the operating room following initial procedure for a related procedure during the postoperative period) for this procedure.

Warning: Be especially careful not to add modifier 78 inappropriately as it also reduces reimbursement. If you are not in the global period of a procedure and you apply modifier 78 inappropriately you might receive as much as 40 percent less reimbursement for no reason. Medicare will only pay for complicated care that requires a return to the operating room (OR) but this does not apply when the previous service does not have a global period or when the global period has expired. Knowing what your payers will cover is key, however. Many insurers will pay for complication care even if your gastroenterologist doesn't return the patient to the OR. Don't give up appropriate reimbursement if the insurer will make payment under CPT's rules.

Example: A Medicare patient develops a minor infection at the surgical wound site, so the surgeon simply  cleans and dresses the wound in his office. The originalprocedure's global surgical package includes the uncomplicated follow-up care. Therefore, you cannot separately report the second procedure for treating the infection. If the patient's infection was severe enough to warrant a return to the OR for treatment, you could report the procedure using modifier 78.