Neurosurgery Coding Alert

If the service you wish to report doesn't quite meet the standards for applying 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), consider these modifier alternatives to meet your coding needs.

- For follow-up procedures during the global period that are related to the patient's initial condition, you would append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate procedure code, explains Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board.

Remember, modifier 78 applies when the patient treats a different condition -- that is, a complication -- related to the initial surgery. Furthermore, modifier 58 denotes a planned or anticipated procedure, whereas modifier 78 "is to be used for unplanned procedure(s) by the physician who performed the initial procedure," according to the AMA's CPT Assistant (Feb. 2008, page 4).

Learn more: For complete information on modifier 58, see "What Qualifies as -More Extensive?- Find Out Now," Neurosurgery Coding Alert, Vol. 9, No. 9, pages 67-68.

- If the surgeon repeats exactly the same procedure during the global period (in other words, if you would report the second procedure using the same CPT code as the first procedure), you should append modifier 76 (Repeat procedure by same physician) rather than modifier 78.

Example: The surgeon performs an L4/L5 diskectomy (63030, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy, and/or excision of herniated disk; one interspace, lumbar) for right leg pain. Although the patient initially improves, she develops recurrent right leg pain one month later. A new MRI shows a disc recurrence. The surgeon again performs an L4/L5 diskectomy 45 days after the initial procedure.

Because the second diskectomy is a repeat of the initial procedure, you would report 63030-76, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

- For a procedure during the global period that is not related to the previous surgery or the underlying condition that prompted the initial surgery, you should access modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

In other words: If the same surgeon must perform a distinct, unrelated surgery -- including all follow-up -- for an unexpected medical condition during a previous procedure's global period, you should append modifier 79 to the subsequent procedure code(s). You must always submit separate, distinct ICD-9 codes for the subsequent surgery to demonstrate medical necessity and show that it is unrelated to the initial surgery.

Example: The surgeon must perform a fusion of cervical vertebrae during the global period of a thoracic fusion/instrumentation. In this case, you would report 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) and append modifier 79 to claim the subsequent fusion.