Neurosurgery Coding Alert

Occasionally, a surgeon must return a patient to the operating room (OR) during the global period of a surgery. To designate that this subsequent procedure is independent and separately payable, the coder must attach a modifier to the appropriate CPT code. Depending on the circumstances that prompt the return to the OR, modifier -58 (staged or related procedure or service by the same physician during the postoperative period), -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) may apply. Although each has a distinct purpose, the similarities among these modifiers can make distinguishing them from one another and applying them properly particularly challenging.
 
Note: Major surgeries, including most neurosurgical procedures, include a 90-day global period.

According to CPT, modifier -58 is applicable 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 results of a previous surgery, dictates the need for additional procedures: Modifier -58 should not be used if subsequent procedures are needed  due to surgical complications or unexpected postoperative findings that arise from the initial surgery (see below for modifier -78).
 
A return to the OR is not required to append modifier -58. The postoperative procedure or service may, for instance, be provided in the physician's office or other outpatient setting. In all cases, however, the same physician must undertake both services/procedures.
 
Most commonly, modifier -58 is used to indicate that a staged procedure, i.e., more than one session generally operative is required to complete the procedure. For instance, a patient has surgery to remove a lesion from the base of the skull, and secondary repair of the dura is necessary to arrest the loss of cerebrospinal fluid. The surgical approach, lesion removal and primary closure (61580-61598 and 61600-61616, as appropriate) are performed during a single, extended operative session. The secondary repair, planned prospectively during the first session, generally occurs days later. This subsequent session would be reported 61618 (secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base ...) with modifier -58 appended to indicate a staged procedure.
 
In a second example, the surgeon implants a pain pump (62350, implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy), expecting that it will be removed within the 90-day global period. He or she brings the patient back to the OR to remove the pump (62355, removal of previously implanted intrathecal or epidural catheter) on the 75th day. Again, modifier -58 is appended to specify that the procedure was staged.
 
Be aware that modifier -58 should not be used to report surgical procedures that by definition may require multiple sessions, e.g., 67141, prophylaxis of retinal detachment one or more sessions. Specific neurosurgical examples of this are rare.

The term "more extensive," as used in relation to modifier -58, is ambiguous and easily misinterpreted. 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 need only go beyond, and be directly related to, the work performed during the initial procedure, Tucker says. Here again, however, the patient's condition (not complications from the initial surgery) must drive the decision to perform an additional procedure(s).
 
For example, a trauma patient arrives in the emergency department with a severe concussion. The neurosurgeon evacuates a hematoma (61312, craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to drain the trapped blood. Several days later, with symptoms persisting, the neurosurgeon performs exploration and evacuates what is found to be an intracerebral hematoma (61313, intercerebral). Modifier -58 is used to indicate that this second surgery was related to, but more extensive than, the initial evacuation.
 
Less commonly, modifier -58 may be used to report therapy following a diagnostic surgical procedure. "Therapy," as used here, includes any measures (including surgery) taken to correct the problem(s) found during the diagnostic surgery. For example, following stereotactic biopsy, aspiration or excision (61751, including burr hole[s], for intracranial lesion) the neurosurgeon excises a brain tumor (61510-61521).
 
Note: If the therapeutic and diagnostic procedures are performed on the same day, modifier -51 (multiple procedures), as well as modifier -58, should be appended to the therapeutic procedure.

Like modifier -58, modifier -78 refers to "related procedure" in its descriptor. Unlike modifier -58, however, modifier -78 applies when the related procedure is caused by conditions arising from the initial surgery, rather than from the patient's condition. This is an important distinction that affects both coding accuracy and reimbursement. Modifier -78 should be used only for complications arising from the original procedure.
 
Note: When in doubt, i.e., the medical record does not clearly indicate the reason for the subsequent surgery, coders should check with the operating physician prior to selecting a modifier.
 
Modifier -78 requires that the patient return to the OR. Unlike modifier -58, modifier -78 cannot be applied in a physician's office or other outpatient setting. Any complications of the initial surgery that may be handled without a return to the operating room, e.g., routine infection, bleeding or perforation, are covered under the global period of that surgery.
 
To apply modifier -78 to any procedure undertaken as a result of a prior surgery, a new, accompanying diagnosis should be selected often (but not exclusively) from the "complications" portion of ICD-9 (998-999.9).
 
For example, a patient develops a hematoma during the global period of a craniotomy (61533, craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring). The patient is returned to the OR to drain the hematoma (61154, burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). In this case, append modifier -78 to 61154 to indicate that the hematoma was a complication of the original surgery. A new diagnosis of 997.02 (iatrogenic cerebrovascular infarction or hemorrhage) should accompany the claim.
 
Modifier -78 differs from modifiers -76 (repeat procedure by same physician) and -77 (repeat procedure by another physician) and applies only when the return to the OR does not result in the performance of an identical procedure, i.e., if the same CPT code describes both the initial and subsequent surgery. If the same procedure is repeated during the global period, report the applicable CPT code with modifier -76 or -77 appended, as appropriate. However, most payers will deny a charge in the global period with these modifiers.
 
Modifier -79: Unrelated Procedure, Same Physician

Modifier -79 is more straightforward than either -58 or -78 and, used correctly, indicates that a subsequent surgery by the same physician, unrelated to either the condition that prompted the initial surgery or the surgery itself, was performed.
 
In other words, if the same surgeon must perform a separate evaluation and undertake a distinct, unrelated surgery including all follow-up for an unexpected medical condition during the global period of a previous procedure, modifier -79 is appropriate. Generally, a return to the OR will be preceded by an E/M service with modifier -24 (unrelated E/M service by the same physician during a postoperative period) appended, during which time the surgeon will determine the need for the subsequent surgery, says Terry Fletcher, BS, CPC, CCS-P, an independent surgery coding specialist in Laguna Beach, Calif.
 
For instance, a patient undergoes a posterior laminectomy, 63045 (laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; cervical). Two months later, the patient falls, leading to new injury. The surgeon performs an evaluation for this new, distinct problem, attaching modifier -24 to the correct E/M code, e.g., 99213, Fletcher says. Surgery is scheduled, and later that week the neurosurgeon performs an anterior fusion, 22554 (arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2). In this case, modifier -79 is attached to 22554 to indicate that this second surgery, occurring during the 90-day global period of the initial surgery, was nonetheless unrelated to the original surgery or the underlying condition that prompted it.
 
As a second example, a patient with carpal tunnel syndrome (354.0) receives surgical treatment to relieve pressure on the left median nerve, 64721 (neuroplasty and/or transposition; median nerve at carpal tunnel). Forty-five days later, the patient is diagnosed with carpal tunnel in the right wrist. Because surgery to treat this problem occurs during the 90-day global period of the first procedure, modifier -79 is attached to 64721.
 
Although the same procedure (64721) was repeated by the same physician, modifier -79 rather than modifier -76 is appropriate because the second problem was diagnosed after the first complaint and did not result from the first complaint. Furthermore, the second surgery occurred in a separate anatomical area (and therefore was not truly "repeated"). Although the same problem (carpal tunnel) was addressed in each case, the two surgeries are unrelated.

Claims filed with modifiers -58 and -79 should be reimbursed at their full value because in each case a separate, complete procedure is reported. Procedures billed with modifier -78, however, include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care, only the surgery itself) and, as such, generally reimburse at 65-80 percent of the full fee-schedule value. If a procedure with "000" global days is billed with modifier -78, the full fee will be paid because such procedures have no pre-, post- or intraoperative values. Be sure to check all payments for claims filed with these modifiers, and appeal as necessary to receive full reimbursement for modifier -58 and -79 claims.
 
Many payers differ from Medicare by not requiring that the second procedure be absolutely unrelated to the initial surgery to bill with modifier -79. That is, they understand that significant postoperative complications may require enough evaluation to begin a new global period and will allow payment at full value. Generally, if they go by CPT guidelines that includes only "normal, uncomplicated follow-up care" in the surgical package, they will allow this approach.