General Surgery Coding Alert

Surgeon must return the patient to the operating room If you want to be sure when to apply modifier 78 -- instead of similar modifiers such as modifier 58 and modifier 79 -- you need only ask yourself 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 would only apply modifier 78 (Unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period) if a subsequent procedure by the same surgeon falls within the global period of an earlier surgery. For instance, you might apply modifier 78 for a procedure that occurs on day 30 following a major surgery with a 90-day global period. Note that 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 appending modifier 78, you should be sure the available documentation substantiates that the surgeon performed the subsequent procedure due to conditions arising from the initial surgery. "When using modifier 78, the procedure is - directly associated with the performance of the initial procedure," stress AMA instructions presented in CPT Assistant (vol. 18, issue 2, February 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, affirms Jo Ann F. Kergides, CPC-H, physician services coder at UMDNJ-SOM Vascular Surgery in Stratford, N.J. Example: Subsequent to endovascular abdominal aortic aneurysm (AAA) repair, the surgeon must place a graft extension (34825, Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel) due to a detected endoleak. If the surgeon places the graft within the 90-day global period of the primary procedure (34800-34804), you would consider modifier 78 because the return to the operating room was neither planned nor included in the original procedure. Tip: If the medical record does not indicate clearly the reason for the subsequent surgery, you should check with the operating surgeon prior to selecting a modifier. 3. Is There a Return to the OR? Finally, the subsequent procedure must require that the surgeon return the patient to the operating room (OR), explains Maggie M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. You cannot [...]