Ob-Gyn Coding Alert

If an ob-gyn patient has to return to the operating room for additional treatment during the global period, you can receive additional reimbursement, as long as you append modifier -78 or -79 to the procedure code. The key is determining whether the secondary procedure is related to the original procedure.

Many coders believe that modifiers -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) are interchangeable, but there are distinct differences between the two that go beyond the fact that modifier -78 refers to a related procedure and -79 refers to an unrelated service. Specifically, modifier -78 does not launch a new postoperative global period, and therefore, any service with modifier -78 appended exists within the original global period.

If you append modifier -79 to a service, however, Section 4822 of the Medicare Carriers Manual (MCM) states, "A new postoperative period begins when the unrelated procedure is billed."

For instance, the ob-gyn performs a total abdominal hysterectomy (58200), and the patient returns 65 days later for a partial vulvectomy (56620).

"In this example, the vulvectomy performed in the post-op period is not a re-operation or treatment for a surgical complication," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Both surgical procedures are clearly unrelated to one another. To report these distinct procedures accurately and to receive appropriate reimbursement, you should append modifier -79 to 56620."

Although the patient only had 25 days left in the original global period, using modifier -79 on the claim will launch a new global period for an additional 90 days.

Suppose an ob-gyn performs a total abdominal hysterectomy (58150) on a patient with a history of poorly controlled diabetes and peripheral vascular disease. The surgical site dehisces postoperatively and begins to bleed. The physician must go back to the operating room (OR) to reclose the wound (49900), Mulholland says.

The first surgery should be coded as 58150, and report the second surgery as 49900-78. Remember that you should append modifiers -78 and -79 to the related or unrelated procedure and not to the original surgery.

If a secondary procedure is required because the patient had the first procedure, then the two services are related. "You should note that documentation that supports the use of this modifier may be requested by your carrier before payment," says Jean Ryan-Niemackl, LPN, CPC, compliance analyst for QuadraMed, a multispecialty coding consulting firm in Fargo, N.D.

Because modifier -78 specifies a "return to the OR," do not use it for subsequent procedures performed in a patient's hospital room, your office, a recovery room or a rehab unit.

"Although most carriers will reimburse for problems that require a return to the OR, be aware that there are carriers out there that will not," Ryan-Niemackl says. "If the return to the OR is done for the bleeding complications within the first 24 hours after surgery, there are carriers that will reject the claim." As with all information, check with your individual payers for their particular rules for using modifier -78.

Medicare should not reduce reimbursement for services appended with modifier -79, but payment varies on a regional basis. Consequently, you should be sure to get your carrier's policy in writing. Always submit separate ICD-9 codes for the unrelated surgeries to demonstrate medical necessity and optimize your chances of full reimbursement. "In addition, when treatment for a complication requires a return trip to the OR, physicians must report the CPT code that describes the procedure(s) performed during the return trip," Mulholland says.

Medicare carriers will reduce your fee when you use modifier -78 to pay only for the intraservice work of the procedure (that is, you will not be paid for the pre- and postoperative care because that is already included in the original procedure). But do not cut your fee on your claim form. Always bill your normal amount and allow them to take the cut from there. This will decrease the chances of your fee being cut twice.