Ophthalmology and Optometry Coding Alert

Modifier -78: The "Complications" Modifier

Modifier -78 refers to a "related procedure" in its description and applies when the related procedure is caused by complications arising from the initial surgery, rather than from the patient's condition. This is an important distinction that affects both coding accuracy and reimbursement. You should use modifier -78 only
for services for complications that arise from the
original procedure.
 
The rationale behind modifier -78 is that every surgery includes a preoperative, intraoperative and postoperative component. When a physician performs two related procedures within the same global period, carriers consider it essentially "double-dipping" if they pay twice for global postoperative care.
 
To use modifier -78, the patient must return to the OR. Medicare defines the OR for this purpose as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The definition of OR includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. The definition does not include a patient's room, a minor treatment room, a recovery room or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR). The term also cannot be applied for related procedures performed in the physician's exam room or minor operating room. Carriers consider any complications of the initial surgery that can be handled without a return to the operating room included in the global period of the initial surgery.
 
Take as an example a case where an ophthalmologist performs cataract surgery on a patient's left eye and then during the 90-day global period following the surgical procedure he performs a YAG capsulotomy (66821, Discission of secondary membraneous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) in the same eye. Since the two procedures are considered related (that is, the patient would not need to undergo the procedure without having had cataract surgery first), then the use of modifier -78 is appropriate. You would code the second surgery as follows: 66821-78-LT.

Modifier -79: Unrelated Procedure, Same Physician

Modifier -79 indicates that the same physician performs a subsequent surgery on a patient for a condition unrelated to either the condition that prompted the initial surgery or unrelated to the surgery itself. In other words, use modifier -79 if the same surgeon must perform a separate evaluation and undertake a distinct, unrelated surgery (including all follow-up) for a medical condition during the global period of a previous procedure.
 
The most common use of modifier -79 reported among our readers is "when billing cataract surgery on a second eye during the global period of the first," says Amanda Kunze, CPC, of Eye & Ear Clinic of Wenatchee in Wenatchee, WA. "Another way that we use modifier -79 is when we are treating a patient with multiple [conditions], and we are having to treat them either with surgery or laser," she adds.
 
For instance, a patient undergoes cataract surgery in her right eye. During the 90-day global period following the original surgery, the patient needs to be seen by the ophthalmologist again for repositioning of a pre-existing intraocular lens prosthesis (IOL) in her left eye. If the physician performs 66825 (Repositioning of intraocular lens prosthesis, requiring an incision [separate procedure]), in the left eye, then the procedure is clearly unrelated to the global surgical package of the previous procedure.
 
You would code the procedure 66825-79-LT and link it to 996.53 (Mechanical complications of other specified prosthetic device, implant, and graft; due to ocular lens prosthesis).
 
If you append modifier -79 to a service, note that Section 4822 of the MCM states, "A new postoperative period begins when the unrelated procedure is billed." So in the case above, if the ophthalmologist performs the procedure 45 days into the global period for the initial cataract surgery, the use of modifier -79 on the claim for the second surgery will launch a new global period for an additional 90 days.