Medicare Compliance & Reimbursement

CMS wants to make it crystal clear: If you are reporting modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), your claims better be airtight.

On Feb. 13, CMS issued a transmittal that advised contractors to "strengthen program safeguards to prevent improper payment for modifier 79." This came on the heels of an OIG report indicating that modifier 79 had a vast potential for fraud.

One of the most common modifier 79 mistakes happens when you try to determine a procedure's relation to the surgery that prompted the global period.

Tip: If the second surgery takes place on a different body part or different side of the body, modifier 79 is usually the right one, says Kerry Sheskier, billing manager with Winthrop University Hospital in Bethpage, N.Y. "If there is a totally different diagnosis and if the doctor notes in his first paragraph that the patient had a previous surgery (with no mention of it being a complication from the first or mentioning it is staged and related to the first)," you've got another clue.