Neurosurgery Coding Alert

Check global period for initial procedure and reason for second procedure.

You may be leaving payment on the table for your surgeon's work if you do not append the correct modifiers for postoperative period procedures. Read on for guidance on how different modifiers can impact global period calculations and your reimbursement.

Know the Common Postoperative Modifiers

Below are the two important modifiers you will append for the procedures your surgeon does in the postoperative period of another.

• 58 -- Staged or related procedure or service by the same physician during the postoperative period
• 78 -- Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

Note: The descriptors of both the modifiers share common terminologies like "related procedure" and "during the postoperative period." You will need to understand what relation is implied by each of the two modifiers.

Example: You may read that your surgeon repeated a craniotomy for a patient who earlier underwent a craniotomy for tumor resection. You will report this re- exploration depending upon the timing and the reason of the re-exploration.

In this case, you check if the re-exploration is performed within the global period of the original craniotomy as a consequence of a postoperative complication. You would then report the craniotomy code with modifier 78. However, if your surgeon did the re-exploration as a part of a planned staged resection of the tumor, you report the craniotomy code with modifier 58.

Use Modifier 58 for Staged Procedures

According to CMS guidelines, you should use modifier 58 when a second procedure in the postoperative period of the initial 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.

Note: The second procedure will share a common underlying cause or condition with the first procedure. The second procedure may not always be planned.

However, the second procedure will be a part of the overall treatment of the underlying problem. Also, modifier 58 does not necessarily need the patient to be taken to the OR for the treatment. "You use modifier 58 when your surgeon either plans a new encounter or another procedure or when the patient requires additional services for the same problem," says Rena Hall, CPC, Kansas City Neurosurgery, North Kansas City, Missouri.

Example: You may read that your surgeon did a craniotomy and a month later returned the patient to the OR to do a cranioplasty with the original craniotomy flap that was placed in a subcutaneous abdominal pocket for later retrieval. You report 62143 (Replacement of bone flap or prosthetic plate of skull) as well as the add-on code for bone graft retrieval 62148 (Incision and retrieval of subcutaneous cranial bone graft for cranioplasty [List separately in addition to code for primary procedure]).

Since this is performed one month after the craniotomy and falls within that global period, you would report both codes appended with the 58 (Staged or related procedure or service by the same physician during the postoperative period) modifier for staged surgery.

Check the global period: When you report the second procedure with modifier 58, you will begin to again count for another global period. "For an example, you may read that a skull base tumor is partially resected and then three months later, stereotactic radiosurgery is performed to treat the remaining tumor.  Since it is the same problem in the same anatomical area with the original diagnosis, the second service, which is an extension of the first, you would utilize modifier 58.  This starts a new global period," says Hall.

Modifier 78 Implies Complications

You append modifier 78 when the second procedure is for a complication that develops consequent to the initial procedure. The return of the patient to the OR in this case is not planned. You should clearly document that the patient was returned to the OR and that the second procedure was to treat the complication. "Modifier 78 is used when there is a complication of the initial surgery," Hall confirms.

The Medicare payers are specific about the return of the patient to the OR. If the patient does not need to be taken to the OR, the service may fall under the initial procedure's global package. Example, a surgical dressing of the infected postoperative wound may be done in an office visit in the global period but may not necessitate the patient's return to OR. This will fall under the global package.

Example: You may read that 40 days following a skull base surgery, your surgeon had to return the patient to the OR for repair of dura to arrest a CSF leak. In this case, you report 61618 (Secondary repair of dura for cerebrospinal fluid leak (CSF) leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts]) for such a repair of dura. Additionally, you will append modifier 78 to indicate a return to the operating room to treat a complication of the original skull base procedure as this is performed within the 90 day global period.

Note: Modifier 78 does not mean that a new global begins after the second procedure. The global period of the initial period continues until 90 days or as applicable. "Because the second procedure is directly related to the original procedure rather than an extension of it, only the global period of the initial procedure applies to both," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. "For an example, you may read that an aneurysm is clipped and three days later, there is a leak requiring an intracranial monitor. In this case, you append modifier 78.  This does not start a new global period," says Hall.

Watch this: Make sure the second procedure is a complication of the initial procedure and the same is documented by your surgeon. You do not 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. In this case, you will rather use modifier 79 (Unrelated procedure or service by the same physician during the postoperative period...). "This situation is a bit more complicated with respect to the effect of global periods. There may be services that occur within the global period of the second procedure that are related to the first procedure and its diagnosis that would be separately reportable," says Przybylski.

Measure the Payment Difference

Your choice of correct modifier affects your payment. This is because modifier 58 but not 78 means a new beginning for the global period. You earn 100 percent of allowable reimbursement for the second procedure when you append modifier 58.

Your reimbursement for the second procedure with modifier 78 will be less as the fee is assigned to the 'intraoperative' work and your surgeon gets no payment for the preoperative and postoperative work for the second surgery. "This payment policy is consistent with the fact that the global period is not extended and that the postoperative services would be a continuation of the services included in the original procedure," says Przybylski.

Remember, you should always confirm the global period for the initial procedure before you report any subsequent procedures with modifiers 58 and 78.