Ophthalmology and Optometry Coding Alert

Same condition or complication makes the difference.

Choosing the appropriate global-period modifier can be confusing, but doing it wrong can leave you over- or underpaid for your ophthalmic surgeon's work. That's because one modifier restarts the global period, while another does not, thus impacting your reimbursement rates.

The following modifiers have similar definitions, sharing the words "related procedure" and "during the postoperative period":

• 58 -- Staged or related procedure or service by the same physician during the postoperative period
• 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.

The similarities leave many coders and billers scratching their heads. Follow our three expert tips to make sure you pick the right modifier -- every time.

Tip 1: Reserve 58 for 'Same Condition'

You should only use modifier 58 when the follow up procedure during the postoperative period arises because of the same condition/problem that prompted the initial procedure. Whether planned or not, the second procedure is the second "stage" of the overall treatment for the original condition.

According to CMS guidelines, you should use modifier 58 when a subsequent procedure in the postoperative period of the first surgery is:

• planned or "staged" or
• more extensive than the original procedure; or
• for therapy following a surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

Often, your surgeon will document each stage of the surgery, including plans for returning the patient to the operating room for additional procedures to manage the patient's condition. However, the planning does not necessarily have to be laid out in the documentation, according to Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

For instance, the last three bullets noted by CMS (above) may not entail noting a plan to return for treatment. Also note that you can use modifier 58 in situations that don't involve a return to the OR.

Hit the restart: The global period restarts when you report the second (subsequent) procedure with modifier 58.

Tip 2: Use 78 for Complications

When the patient suffers a complication from the first surgery that requires an (unplanned) return to the operating room during the global period, you should append modifier 78 instead of 58. Note that a complication is an unexpected and different condition than the problem that prompted the original surgery.

Unlike modifier 58, the patient must return to the OR before you can use modifier 78. In fact, Medicare payers consider treatment for complications that don't require a return to the OR part of the original procedure's global package, such as an office visit to clean and dress a minor infection at the surgical wound site.

Caution: Don't use modifier 78 when the patient's condition that requires a second procedure is not related to the original condition or a complication of the original surgery. Such a case warrants appending modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Same global: In contrast to modifier 58, using modifier 78 does not trigger a new global period.

Tip 3: Prepare for Payment Difference

Because 58 restarts the global period while 78 does not, your modifier choice will have payment ramifications. The surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures when you use modifier 58, but not 78.

78 lowers pay: Modifier 78 results in a reimbursement decrease, with payment based on the portion of the fee assigned to the "intraoperative" work. In other words, the surgeon doesn't receive pay for the pre-op and post-op work for the second surgery, because it's still part of the original global period. For Medicare claims, you should expect a reduction of anywhere from 15-30 percent of your reimbursement.

Watch global days: Some surgical procedures have had recent changes in global days, with reductions from 90-day to 10-day or even to 0-day. "Almost all endoscopic procedures and transvascular procedures have 0 global days. If you use modifier 78 for a return to the OR for a complication after a procedure performed via one of those approaches, you are likely inappropriately reducing your reimbursement," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

You should also avoid a common coding error involving the inappropriate use of modifier 58 with services that do not have a postoperative period, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.