General Surgery Coding Alert

The Procedure: A 46-year-old male undergoes bypass graft (35661) for artherosclerotic cardiovascular disease (ASCD). Several weeks later, the patient must have an above-the-knee amputation with gangrene. A different surgeon in the same practice performed the amputation.

The Challenge: A California reader wants to know: "Is the amputation related or unrelated to the bypass? In other words, should I append modifier -78 or -79 to the second procedure code?"

The Solution: In this case, the first surgeon probably planned to proceed with the amputation if the bypass graft did not work. Further, the amputation in this case is not a complication of the earlier surgery but a result of the underlying disease (the ASCD). Therefore, you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) rather than -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period).

Modifier -58 is applicable, according to CPT guidelines, when a procedure or service during the postoperative period is:
a) planned prospectively at the time of the original procedure (staged);
b) more extensive than the original procedure; or
c) for therapy following a diagnostic surgical procedure.

In each case, the subsequent procedure or service is either related to the underlying problem/diagnosis that prompted the initial surgery or anticipated at the time the initial surgery is performed (or both), says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues in Fountain Valley, Calif. The patient's condition, rather than the previous surgery results, dictates the need for an additional procedure (therefore, any additional surgery is not due to a complication of the initial surgery, but of the disease itself).

The term "more extensive," as used in relation to modifier -58, is ambiguous and easy to misinterpret, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb. In this case, a more extensive procedure need not be more complex or time-intensive than the original procedure (although it often is). Rather, the subsequent procedure should only go beyond, and be directly related to, the work the surgeon performs during the initial procedure.

The surgeon need not return the patient to the operating room to append modifier -58, Tucker says. The surgeon may provide the postoperative procedure or service, for instance, in his or her office or any other.

But in all cases, the same physician must undertake both the initial and the follow-up service(s)/procedure(s). Remember that Medicare treats physicians of the same specialty in the same group practice (that is, physicians using the same personal identification number, or PIN) as the "same." Therefore, you must still append modifier -58 even though a different physician in the same practice performed the follow-up surgery. Had a surgeon billing with a different PIN performed the second surgery, you would not need to append modifier -58.