Neurosurgery Coding Alert

Remember: The subsequent surgery requires a return trip to the OR.

In certain situations, your neurosurgeon may need to perform an unplanned procedure during a patient’s postoperative period. In this case, you should check the medical documentation to see if the claim warrants a modifier, namely modifier 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).

Take the following quiz to see if your modifier 78 knowledge would make the grade.

Understand When to Appropriately Append Modifier 78

Question 1: I’ve been researching more about modifier 78, but I’m still confused about when I should append this modifier to claims. Can you please help me?

Answer 1: One coding expert has made an easy mnemonic device out of modifier 78, which helps explain when to use it.

“I use the rhyme 78-relate, and that pretty much says it all,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “If a patient requires a return trip to the OR [operating room] that is directly related to a procedure that took place within the last 90 days, the 78 modifier is appended.”

There are several instances in which you might use modifier 78, but the important elements of each encounter are whether the service was related to the original surgery and whether or not the surgeon returned the patient to the OR.

“Often the quandary is whether the service was planned/staged or unplanned, but related,” Hauptman says. “A staged procedure would be a 58 modifier [Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period], while the 78 is for that unplanned trip. Keep in mind that it must be trip to the OR. If another procedure is needed and performed at the bedside or in the office, it cannot have the 78 appended to it as it is included in the global surgical package.”

Brace Yourself for Reduced Pay With Modifier 78

Question 2: My colleague told me that if I append modifier 78 to a claim, my surgeon should expect to see reduced payment. Is this true?

Answer 2: Yes. Coders can expect reduced payment for any modifier 78 claims, experts say.

“Modifier 78 results in reduced reimbursement because there is not a new global period; only the intraoperative part of the reimbursement is paid,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Don’t Mix Up Modifier 78 With Modifier 79

Question 3: I keep mixing up modifier 78 with modifier 79. Can you help me distinguish between the two?

Answer 3: As 78 is for related procedures, modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period)  “is for procedures performed that are unrelated to the one performed within the last 90 days [the original global surgical period],” Hauptman says. “If the procedure is totally unrelated, the 79 would be appended, and a new 90-day global period would be set in motion around the second procedure.”

It’s important to remember that the second procedure, the one with modifier 79, is unrelated, says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. It’s not a planned return for a staged procedure or a return to the OR for a complication or other related procedure. Therefore, a new ICD-10 code would be expected to be reported with the second unrelated procedure.

“One example of this would be a patient with ‘double-crush’ syndrome where a combination of C6 radiculopathy from cervical spondylosis and carpal tunnel syndrome are concurrently causing hand numbness,” Przybylski explains. “If both the cervical spondylosis and carpal tunnel syndrome are surgically treated on different days, but within 90 days of one another, the second procedure(s) would be appended with the 79 modifier and associated with a different ICD-10 code.”

Ask Yourself 3 Questions Before Appending Modifier 78

Question 4: Can you give me a few key questions to ask myself when I’m considering whether to append modifier 78?

Answer 4: When you are looking through your surgeon’s medical documentation, you can ask yourself three questions before appending modifier 78. If you can answer “yes,” to all three questions, then the situation may warrant a modifier 78.

Take a look at the following example: 40 days following a skull base surgery, my surgeon had to return the patient to the OR for a repair of dura to arrest a cerebrospinal fluid leak (CSF) leak in the anterior cranial fossa (61618). The surgeon used a free tissue graft for the secondary dura repair.

• Is the subsequent procedure related to the initial surgery? Remember, you can only append modifier 78 if the surgeon undertook the subsequent surgery because of complications from an initial surgery. You can answer “yes” for this example because the surgeon performed the subsequent surgery, the secondary repair of the dura for a CSF, because of complications from the initial surgery, the skull base surgery.
• Does the procedure fall within a global? Remember, the subsequent surgery must occur during the 90-day global period of the initial surgery. For this example, the surgeon performed the subsequent surgery 40 days after the initial surgery, so you can answer “yes,” to this question.
• Lastly, was there a return to the OR? Remember, the subsequent surgery requires a return to the OR. In the documentation, it states that the surgeon returned the patient to the OR to treat a complication of the original skull base procedure, so the answer to this question is “yes.”

Solution: Since you can answer “yes,” to all of the three questions above, you should report 61618 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts)) with modifier 78 appended.