General Surgery Coding Alert

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.

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.

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.

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 append 78 if the physician treats the complication(s) in the office.

Your surgeon performs a splenectomy (38100, Splenectomy; total [separate procedure]). During the post-operative period, the patient develops a significant wound dehiscence. The surgeon returns the patient to the OR to treat the dehiscence (13160, Secondary closure of surgical wound or dehiscence, extensive or complicated) that is related to the first procedure.

In this case, you would report 13160 with modifier 78 to show a return to the OR to treat the complication of the previous surgery. You should link 13160 to a new primary diagnosis of wound dehiscence (998.3x, Disruption of operation wound; dehiscence of operation wound).

This service meets all requirements for modifier 78:

1. The subsequent procedure by the same surgeon occurs within the global period of the initial procedure;

2. the subsequent procedure is a complication of the initial procedure, and

3. the subsequent procedure requires a return to the OR.

For CMS, no OR means no separate coding: For Medicare carriers, you cannot charge separately for complications that the surgeon handles in an outpatient setting. These could include infection, bleeding or perforation. The surgery's global period covers such services, according to the Medicare guidelines.

For instance, the patient in the example above develops a minor infection at the surgical site, and 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.

Watch for private payer exception: Private payers, however, may allow you to report a separate service if the surgeon treats a complication in the office.

For instance, if the surgeon inspects and cleans a post-operative infection, changes the patient's dressings and administers antibiotics, non-Medicare payers may allow you to report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 24 (Unrelated evalua tion and management service by the same physician during a postoperative period) appended.

Here's why: Payers following CPT guidelines do not consider postoperative infections as necessarily "related" to the initial surgery. Modifier 24 indicates to the payer that the E/M service during the global period of the initial service is for a "new" problem (that is, the post-operative wound infection) and is therefore not bundled as part of the global surgical package.

When you-re filing claims with modifier 78, you shouldn't expect to receive the full fee schedule reimbursement amount. Procedures billed with modifier 78 include only the service's "intraoperative" portion, and carriers generally reimburse them at 65-80 percent of the full fee schedule value, says Patrice Young, CPC, CMSCS, with Commonwealth Orthopaedic Associates in Pennsylvania. In other words, if you report a procedure with modifier 78, you will not receive the portion of payment assigned to the pre- and postoperative care usually associated with that procedure.

Note, however, that the global period for the original surgery is not "reset" by the return to the OR as described by modifier 78, advises Lisa Rickert with Doctor's Billing Inc. in Hanover, Mass.