General Surgery Coding Alert

You need a return to the OR to apply -78

When attempting to decide between modifiers -78 and -79 for a procedure during the postoperative period of another surgery, the most important question you must ask yourself is, "Would the second surgery have been necessary if the first surgery hadn't occurred?" When circumstances arising from the initial surgery necessitate the second surgery, you should turn to -78.

Meet 3 Guidelines for -78

You should apply modifier -78 (Return to the operating room for a related procedure during the post-operative period) when:

1. the surgeon must undertake the subsequent surgery because of conditions arising from the initial surgery

2. the subsequent surgery occurs during the global period of the initial surgery

3. the subsequent surgery requires a return to the operating room (OR).

You should think of modifier -78 as the "complications" modifier, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

Example: Several days following hernia repair (for example, 49560, Repair initial incisional or ventral hernia; reducible) the patient develops an infection at the incision site. To treat the infection, which has become fairly serious, the surgeon returns the patient to the OR for debridement (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface).

In this case, you should report 11000-78, Allen says

Bundle Procedures That Don't Require OR Visit
 
For Medicare carriers, you cannot charge separately for complications that the surgeon handles in an outpatient setting. These could include infection, bleeding or perforation, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. Such services are covered under the surgery's global period, according to Medicare guidelines.

For example: The patient in example 1, above, develops a minor infection at the site of the surgical wound. In this case, the surgeon simply cleans and dresses the wound in his office. In this case, the global surgical package of the original procedure (that is, the hernia repair, 49560) includes the uncomplicated follow-up care.

Apply -79 for Brand-New Circumstances

You should apply modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) when:

1. the surgeon must undertake the subsequent surgery for conditions unrelated to the initial surgery

2. the subsequent surgery occurs during the global period of the initial surgery

3. a non-Medicare patient develops a complication that can be treated without a return to the operating room.

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

Example: The surgeon creates a venous fistula (for example, 36825, Creation of arteriovenous fistula by other than direct arteriovenous anastomosis [separate procedure]; autogenous graft) for a 48-year-old renal failure patient. Nine days later, the patient's fistula becomes clotted. The same surgeon re-evaluates the patient and performs thrombectomy (for instance, 36831, Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft [separate procedure]) to remove the clot during the global period of the initial surgery.

In this case, you should report the second procedure as 36831-79 to indicate that the decompression was unrelated to the initial surgery.