Neurosurgery Coding Alert

Turn to condition, complication to make a choice.

When reporting neurosurgical procedures, you will commonly come across situations wherein your surgeon did a postoperative management. You will be faced with a challenge to determine if the management in the postoperative period was planned and staged or unplanned. Read on to learn how to make the correct code choice.

You may notice similar definitions in descriptors for the following modifiers:

• 58 -- Staged or related procedure or service by the same provider during the postoperative period
• 78 -- Return to the operating room for a related procedure during the postoperative period.

Note that these descriptors share the words "related procedure" and "during the postoperative period:"

These similarities can pose challenges in code selection. Follow the tips below to pick the right modifier, each time you need to report one.

Tip 1: Reserve 58 for 'Same Condition'

You should only use modifier 58 when the follow up procedure during the postoperative period arises because of the same condition/problem that prompted the initial procedure. Whether planned or not, the second procedure is the second "stage" of the overall treatment for the original condition.

According to CMS guidelines, you should use modifier 58 when a subsequent procedure in the postoperative period of the first surgery is:

• planned or "staged"; or
• more extensive than the original procedure; or
• for therapy following a diagnostic surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

Often, your surgeon will document each stage of the surgery, including plans for returning the patient to the operating room for additional procedures to manage the patient's condition. However, the planning does not necessarily have to be laid out in the documentation, according to Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

For instance, the last three bullets noted by CMS (above) may not entail noting a plan to return for treatment. Also note that you can use modifier 58 in situations that don't involve a return to the OR.

Hit the restart: The global period restarts when you report the second (subsequent) procedure with modifier 58.

Tip 2: Use 78 for Complications

When the patient suffers a complication from the first surgery that requires an (unplanned) return to the operating room during the global period, you should append modifier 78 instead of 58. Note that a complication is a different condition than the problem that prompted the original surgery.

Unlike modifier 58, the patient must return to the OR before you can use modifier 78. In fact, Medicare payers consider treatment for complications that don't require a return to the OR part of the original procedure's global package, such as an office visit to clean and dress a minor infection at the surgical wound site.

Caution: Don't use modifier 78 when the patient's condition that requires a second procedure is not related to the original condition or a complication of the original surgery. Such a case warrants appending modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). Since a different condition is being treated in this second procedure, a different diagnostic code is necessary. "Each procedure and its respective postoperative follow-up will carry its own global period," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience

Institute, JFK Medical Center, Edison. "It is important to keep track of the reason that a subsequent postoperative visit occurs, because it may be separately billable if attributable to the diagnosis of the first procedure (once its global period has expired) despite still being in the global period of the second procedure," he adds.

Same global: In contrast to modifier 58, using modifier 78 does not trigger a new global period.

Tip 3: Prepare for Payment Difference

Because 58 restarts the global period while 78 does not, your modifier choice will have payment ramifications. The surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures when you use modifier 58, but not 78.

78 lowers pay: Modifier 78 results in a reimbursement decrease, with payment based on the portion of the fee assigned to the "intraoperative" work. In other words, the surgeon doesn't receive pay for the pre-op and post-op work for the second surgery, because it's still part of the original global period. For Medicare claims, you should expect a reduction of anywhere from 15-30 percent of your reimbursement. "Procedures can vary greatly in terms of the proportional value of the intraoperative work when compared with the preservice and postservice work," says Przybylski.

Watch global days: Some surgical procedures have had recent changes in global days, with reductions from 90-day to 10-day or even to 0-day. "Almost all endoscopic procedures and transvascular procedures have 0 global days. If you use modifier 78 for a return to the OR for a complication after a procedure performed via one of those approaches, you are likely inappropriately reducing your reimbursement," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

You should also avoid a common coding error involving the inappropriate use of modifier 58 with services that do not have a postoperative period, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.