Neurosurgery Coding Alert

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 the second surgery is required because of circumstances arising from the initial surgery, you should turn to -78 (Return to the operating room for a related procedure during the postoperative period).

Meet 3 Guidelines for -78

You should apply modifier -78 when:

1. the surgeon must undertake the subsequent surgery because of complications from an 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 -78 as the "complications" modifier, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla.
 
Example 1: Several weeks following diskectomy (for example, 63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteo-phytectomy; cervical, single interspace), the patient develops an infection at the site of the surgical incision.
 
To treat the infection, 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.

Example 2: A patient develops a hematoma two days following a craniotomy (61533, Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring). The surgeon returns the patient to the OR to drain the hematoma (61154, Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural).

Once again in this case, you should append modifier -78 to 61154 to indicate that drainage resulted as a complication of the craniotomy.

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 Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. Such services are covered under the surgery's global period, according to Medicare guidelines.

For example: The patient in example 1 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. The global surgical package of the original procedure (that is, the diskectomy, 63075) includes this 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.

In other words, Jandroep 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 3: The surgeon performs spinal decompression 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disk], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disk]) on a 48-year-old male patient.

Nine weeks later, the patient falls at home and injures a separate spinal area. The same surgeon re-evaluates the patient and performs the second decompression (for instance, 63055, ...thoracic) during the global period of the initial surgery.

In this case, you should report the second procedure 63055-79 to indicate that the decompression was unrelated to the initial surgery.