Neurosurgery Coding Alert

Decide first if the procedure is related to or a complication of a previous surgery

Can you easily distinguish between modifiers -58, -78 and -79? If not, you'll need to brush up on some modifier basics. Knowing when to apply each of these modifiers can mean the difference between complete reimbursement and costly claim denials.

You should apply modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) when a procedure or service during the postoperative period is:

a) planned prospectively at the time of the original procedure (staged), or
b) more extensive than the original procedure, or
c) for therapy after 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 surgeon performs the initial surgery (or both), according to CPT instructions.

In other words, the patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. You should not use modifier -58 if the patient needs a follow-up procedure because of surgical complications or unexpected postoperative findings that arise from the initial surgery.

The surgeon does not need to return the patient to the operating room (OR) to use modifier -58. The surgeon may provide a postoperative procedure or service, for instance, in his office or other outpatient setting.

Typically, you append modifier -58 to identify a staged procedure (a procedure that requires more than one operative session to complete). 

Here's an example: A patient undergoes surgery to remove a lesion from the base of the skull. The surgeon must also perform secondary repair of the dura to arrest the loss of cerebrospinal fluid.

The surgeon undertakes the surgical approach, lesion removal, and primary closure (61580-61598 and 61600-61616, as appropriate) during a single, extended operative session. The secondary repair, planned prospectively during the first session, generally occurs days later. You should use 61618 (Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base ...) to report this subsequent session with modifier -58 appended to indicate a staged procedure.

Don't Be Confused by 'More Extensive'

A"more extensive" procedure to which you append modifier -58 doesn't need to be more complex or time-intensive than the original procedure (although it can be). Rather, the surgeon's subsequent procedure need only be more extensive than the work he performed during the initial procedure, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzburg, Ill.

Here again, however, the patient's condition - not complications from the initial surgery - must drive the decision to perform an additional procedure(s).

Coding Example: Atrauma patient with a severe concussion arrives in the emergency department. 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 an intracerebral hematoma (61313, ... intracerebral). You should apply modifier -58 to indicate that this second surgery was related to, but more extensive than, the initial evacuation.

If It's a Complication,Turn to -78

You should apply modifier -78 (Return to the operating room for a related procedure during the postoperative period) when conditions arising from the initial surgery - rather than the patient's condition - call for a related procedure, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla. In other words, you should append modifier -78 to procedures required because of complications arising from the original procedure.

Note: If the medical record does not clearly indicate the reason for the subsequent surgery, you should check with the operating physician prior to selecting a modifier.

Without a return to the OR, don't apply -78:
Modifier -78 also requires that the surgeon return the patient to the OR. Any initial surgery complications that the surgeon handles in an outpatient setting, such as infection, bleeding or perforation, are covered under the surgery's global period, according to Medicare guidelines. Payers that follow CPT guidelines may allow payment for services that go beyond "typical postoperative follow-up care" if you append modifier -79 to the appropriate procedure code (see below).

Coding Example: Apatient 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 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). In this case, append modifier -78 to 61154 to indicate that the hematoma was a complication of the original surgery.

If the surgeon performs a second, unrelated surgery during the global period of an initial surgery, you should append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the subsequent surgery code.

In other words, if the same surgeon must perform a separate evaluation and a distinct, unrelated surgery -including all follow-up - for an unexpected medical condition during the global period of a previous procedure, you should append modifier -79 to the subsequent procedural code(s).

Use -24 for E/M

Generally, the surgeon will perform a separate E/M service for the new problem before returning to the OR. You may report this E/M service by appending modifier -24 (Unrelated E/M service by the same physician during a postoperative period) to the appropriate E/M service code, Sandham says.

Coding Example: Apatient undergoes 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 (for example, 99213). Four days later the neurosurgeon performs an anterior fusion (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) to correct the injury.

In this case, append modifier -79 to 22554 to indicate that the second surgery, which occurs during the global period of the initial surgery, was unrelated to the original surgery or the underlying condition that prompted it.