Gastroenterology Coding Alert

Can you easily distinguish between modifiers 58, 78, and 79? If not, you'll need to brush up on some modifier basics. Knowing when to apply each can mean the difference between complete reimbursement and costly claim denials.

Complications: You'll report modifier 78 (Unplanned return to the operating room for a related procedure during the postoperative period) when conditions arising from the initial surgery (complications) " rather than the patient's condition -- call for a related procedure.

Staged procedures: You should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) when a procedure or service is planned or anticipated at the time of the original procedure (staged), is more extensive than the original procedure, or represents therapy following a surgical procedure.

Tip: You need not return the patient to the operating room to report modifier 58. You must, however, return the patient to the OR to qualify for modifier 78.

Suppose the physician places a gastrostomy tube (49440), but eight days later, the tube leaks and the doctor returns the patient to the OR to change the tube. Would this warrant modifier 78 or 58 to be appended to the tube change code (43760)?

Solution: You should append modifier 78 to the second procedure, advises Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. "The initial procedure (49440) has a 10-day global and the leak wasn't planned, so for the physician to get paid for this service, the modifier would be required."

How can you tell? When trying to determine whether a procedure was "staged," check the physician's notes, because he'll often indicate that another procedure is planned. "In the final summary of the procedure, the physician would possibly state, 'The patient is to return to the office in x number of days for x procedure,'" says Doug Williams, CPC, business office manager at Consultants In Gastroenterology in Columbia, S.C.

Keep in mind: "There would be very few instances that a gastroenterologist would use the modifier 58," Parks says. "This modifier is normally used on procedures with 10 to 90 global days."

What if no OR trip takes place? Medicare payers consider all postoperative complications "related" to the initial surgery unless the patient must be returned to the operating room.

For instance, suppose a patient develops a minor  infection at the surgical wound site. The surgeon simply cleans and dresses the wound in his office. In this case, the original procedure's global surgical package includes the uncomplicated follow-up care.

When modifier 79 counts: If, however, you must return a patient to the operating room for an unrelated procedure during the global period of the first surgery, you should append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the subsequent procedure code.

In other words, if the same surgeon must perform a separate, unrelated surgery -- including all follow-up -- for an unexpected medical condition during the global period of a previous procedure, you should append modifier 79 to the subsequent procedural code(s).