Neurosurgery Coding Alert

Don't miss out on extra pay when global period resets.

Just because you routinely append modifiers to your claims doesn't mean you're filing correctly and getting the most appropriate pay. Brush up on your modifier know-how with these tips for three of the trickiest choices: modifiers 58, 78, and 79.

Remember All Possible Uses for 58

The descriptor for modifier 58 seems self-explanatory: Staged or related procedure by the same physician during the postoperative period. Coders sometimes trip, however, when they forget that modifier 58 actually applies to subsequent procedures that fall into one of three categories:

Planned or anticipated (staged): An example of when you might use modifier 58 in this situation would be if your neurosurgeon retrieves a cranial bone graft (+62148) and repairs the skull (62143) 10 weeks from the date of the initial hematoma evacuation (61312) and temporary bone flap implantation (+61316). Because the cranial repair takes place within the global period of the initial surgery, and because the repair was a planned procedure, you should append modifier 58 to 62143 and +62148.

"You won't use a modifier on the first procedure, but will add modifier 58 on the subsequent procedures," says Elisabeth Janeway, CCP, CPC, CCS-P, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

More extensive than the original procedure: For example, if your neurosurgeon discovers and treats a new lesion during the 90-day global period of an original stereotactic radiosurgery treatment, you should once again report.

61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion), but you would append modifier 58 to show that this is a related, "more extensive" procedure. Therapy or treatment following a surgical or diagnostic procedure: This could apply to a soft tissue biopsy followed at a later date by malignant tumor excision, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network, LLC. Although knowing about the option is good for coders, Janeway points out that physicians rarely use modifier 58 in these situations.

Global tip: You'll only append modifier 58 to the second procedure if it occurs during the first procedure's global period. The date of the second procedure resets the global period. You should expect 100 percent reimbursement for procedures you file with modifier 58. Make sure you deserve the reimbursement, Janeway advises, before you append the 58. Verify 'Surprise' Before Reporting 78 If your neurosurgeon completes a second -- but unplanned -- procedure related to the first, you might need modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). Before appending modifier 78, confirm that the follow-up procedure was related to the original procedure but unplanned and that it occurred during the global period.

Example: A patient presents with a subdural hemorrhage and requires a craniotomy. A few days later the patient has a recurrent subdural hemorrhage that requires evacuation via a burr hole on the same side. You'll report the craniotomy with 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) and diagnosis 432.1 (Subdural hemorrhage), then the burr hole with 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). Because the recurrent subdural did not result from a complication of the original surgery (as opposed to the disease process), report diagnosis 432.1 again.

Because your surgeon performed the second procedure within the craniotomy's global period, you'll need to include a modifier explaining the situation. Since the burr hole was in the same location, you'll use modifier 78 with 61154.

Pay change: Because the second procedure was related to the global procedure and was unplanned, the original procedure's global period stays intact. The second procedure's global period begins on the date of that surgery. Expect a reduction in pay for the second procedure, however -- anywhere from 50 percent to 70 percent of the allowable charge, experts say.

"Private insurers tend to pay more for procedures with modifier 78 than Medicare's typical 69 percent," Janeway says. "Make sure there was a return to the OR, especially for Medicare --

Medicare won't pay if the physician performs the procedure in the patient's room."

Check All Diagnoses to Justify 79

Sometimes a patient returns to the operating room for a procedure that's not related to the first surgery, but still within the first procedure's global period. In that case, you'll consider appending modifier 79 (Unrelated procedure or service by same physician in the postoperative period).

Caveat: Before reporting modifier 79, verify that your physician does not perform the second procedure because of complications related to the first. You must have a different diagnosis supporting the return to surgery and your use of modifier 79.

For example, if the patient in the example above actually needed a burr hole on the opposite side (rather than a recurrence at the same site as the original surgery), you'll append modifier 79 rather than 78.

You should receive full reimbursement for the second procedure because a new global period starts with the unrelated procedure. "Each line item should get modifier 79 if the surgeon performs more than one unrelated procedure," notes Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. And because you'll be dealing with multiple global periods, monitor followups carefully to ensure you correctly track the patient's care.