Gastroenterology Coding Alert

Hint: The physician must return the patient to the operating room.

Need to know when to apply modifier 78 instead of similar modifiers such as 58 and 79? Just ask yourself these three questions. If all the answers come up “yes,” you can safely assume that 78 is your modifier of choice.

1. Does the Procedure Fall Within a Global?

You only apply modifier 78 (Unplanned return to the operating/procedure room by the same physician following  initial procedure for a related procedure during the postoperative eriod) if a subsequent procedure by the same surgeon falls within the global period of an earlier surgery.

Example: Your gastroenterologist places a gastrostomy tube -- 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) -- but eight days later, the tube leaks and the physician returns the patient to the operating room to change the tube.

You must append modifier 78 to 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) for the second procedure because 49440 carries a 10-day global period. If you report 43760 without a modifier within that period, the payer may deny the service as included in the earlier 49440 service.

Note: Modifier 78 is not the only modifier that may apply for procedures during the global period. You must satisfy two more conditions before you can select modifier 78 confidently.

2. Is the Procedure Related to the Initial Surgery?

When you append modifier 78, be sure your physician documented that he performed the procedure due to conditions arising from an initial surgery.

When using modifier 78, the procedure is directly ssociated with the performance of the initial procedure, say AMA instructions presented in CPT Assistant (Feb. 2008, page 3).

In other words: You should append modifier 78 when coding for the surgeon's effort to deal with complications, such as infection or separate control of bleeding.

A complication may be related to the initial procedure, but it is not related to the patient's initial condition, said Jo Ann F. Kergides, CPC-H, a physician services coder in Stratford, N.J.

Example: Your gastroenterologist performs a flexible sigmoidoscopy with control of bleeding to remove rubber bands within the global period of a rubber-band ligation 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]).

You may report the sigmoidoscopy separately using 45334 (Sigmoidoscopy, flexible; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). You should append modifier 78 to 45334 to indicate that the gastroenterologist performed the second procedure because of a complication related to the initial rubber-band ligation (46221).

Tip: If the medical record does not indicate clearly the reason for the subsequent procedure, you should check with the gastroenterologist prior to selecting a modifier.

3. Is There a Return to the OR?

Modifier 78 requires that the physician return the patient to the operating room (OR) or procedure room, which can include an endoscopy suite, Medicare says.

Warning: You should use modifier 78 only for complications of the initial surgery that require a return to the OR or procedure room.

If your gastroenterologist can handle the complication without heading to the OR or procedure room, the service is part of theinitial surgery's global period.

Example: A patient has hemorrhoids, and the gastroenterologist cauterizes three internal hemorrhoids with a heater probe.

The next day, the patient calls to complain about 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:

 report 46934 (Destruction of hemorrhoids, any-method; internal) for the hemorrhoid removal)
 attach 455.2 (Internal hemorrhoids with other complication) to 46934

 report 45334 for the sigmoidoscopy

 attach 569.42 (Anal or rectal pain) and 569.3 (Hemorrhage of rectum and anus) to 45334

 append 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).

This service meets all requirements for modifier 78:

1. The subsequent procedure by the same gastroenterologist occurs within the global period of the initial procedure.
2. The subsequent procedure is a complication of the initial procedure.
3. The subsequent procedure requires a return to the endoscopy suite.