Oncology & Hematology Coding Alert

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: Appendix A in the CPT^® code book explains that modifiers:

1. Provide “the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code,” and

2. “Enable health care professionals to effectively respond to payment policy requirements established by other entities.”

Or, to put it another way, a modifier alters the code’s intention because there is a special circumstance of the CPT^® code you are reporting, but you are not actually changing the definition of the code itself, explains Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of KnowledgeTree Billing, Inc.

Answer 2: Confusing modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) with modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure by another physician or other qualified health care professional) is understandable, but there’s an easy way to distinguish between them.

Use 76 or 77 when the second procedure is a repeat of the first procedure, and differentiate them this way:

• Attach 76 when the same provider administers a second, identical service after the first service on the same day.
• Append 77 when a different provider administers the second, identical service on the same day.

You’ll typically only use these modifiers with codes for medicine and radiology services. They are not appropriate for laboratory, evaluation and management (E/M) codes, or surgical procedures for Medicare.

For laboratory tests: You would pick modifier 91 (Repeat clinical diagnostic laboratory test) for repeat laboratory procedures on the same day.

For E/M services: You would use modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) (for office/ outpatient) or 27 (Multiple outpatient hospital E/M encounters on the same date) (for facility) for repeat, necessary E/Ms on the same day.

For surgical procedures: You would pick modifier 79 in a situation where the patient has returned for a second procedure during the first procedure’s global, or postoperative period, and the reason for the second service has no relationship to the reason for the first.

For example: A female patient with persistent endometrial intraepithelial neoplasia undergoes a total laparoscopic hysterectomy and bilateral salpingectomy (TLH/BS) coded to 58573 (Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)). At some point during the 90-day global period of the initial surgery, the same patient returns for a simple vulvectomy, coded to 56620 (Vulvectomy simple; partial), to remove a lesion. If the same surgeon performs the vulvectomy, and since the two procedures are unrelated, you would append modifier 79 to 56620.

Remember: “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,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America.

Answer 3: You use 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) when the same surgeon, or a surgeon in the same practice and specialty, returns a patient to surgery and the service meets the following three special circumstances:

• The subsequent procedure falls within the global period of the initial surgery;
• The surgeon returns the patient to the operating room (OR) for Medicare/procedure room (for other payers); and
• The subsequent procedure is related to the initial surgery, such as a complication, but was not planned or staged as a second part of the initial surgery.

For example: The same surgeon performs a subsequent procedure to treat an unintended outcome of the previous surgery, such an infection or hemorrhage incurred as a result of the initial surgery, and it requires a return to the OR.

Memory aid: “I use the rhyme ‘78-relate,’ and that pretty much says it all,” explains Hauptman. You use modifier 78 if the patient requires a return trip to the OR that is directly related to a procedure that took place within the past 90 days (or applicable global period), she says.

Caution: If a surgical oncologist performs an unplanned procedure during the global period at the bedside or office instead of the OR, the global period includes the service and you shouldn’t use modifier 78.

Answer 4: Use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) for a second procedure that was planned along with an earlier procedure when the provider performs the second procedure during the global period assigned to the first. So, if your provider performs a procedure that results in documented rationale that the patient will need to return later for another portion of the service, and it will happen within the postoperative period, attach 58 to the return procedure.

Example: A patient has a malignant melanoma removed from their shoulder and the physician takes a lymph node biopsy coded to 38510 (Biopsy or excision of lymph node[s]; open, deep cervical node(s)) and notes removal will be pending the results of the biopsy. The pathology determination reveals the lymph node involves metastatic malignancy, so the physician orders and schedules the lymph node dissection, which you would document and report with a code such as 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple) with modifier 58 appended as long as it was within the global period of the biopsy.

Coding tip: Be sure the physician documents the potential return in their initial treatment plan in their operative report before using modifier 58.

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