Orthopedic Coding Alert

Subtle differences between 58 and 78 will unlock payment

Orthopedic surgeries often require more than one step, so you're probably familiar with reporting staged and related procedures during global periods - the real test is determining how to code when the surgeon returns the patient to the OR more than once for the same injury.

Test your knowledge of which modifier you should append with this complex foot surgery case study, which required three trips to the operating room (OR) before the surgery was complete.

Scenario: The orthopedic surgeon performed a hospital consult (99252) for a patient with a severe toe infection and determined that the patient required immediate surgery for incision and drainage (28003, Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas).

Because the patient had such a deep and severe infection, the surgeon did not close the wound so he could wait until the infection subsided before he decided whether to amputate the toe.

Three days later, the surgeon determined that he needed to amputate the patient's third toe (28820, Amputation, toe; metatarsophalangeal joint). He still left the site open to clear up the infection. Four days later, the surgeon took the patient back to the OR to perform a secondary closure (13160, Secondary closure of surgical wound or dehiscence, extensive or complicated).
 
Coding dilemma: Which modifier best applies to the scenario: modifier 58 or 78?
 
Get Familiar With Your Options

If you are unclear how to approach this scenario, check out this "cheat sheet" that explains each modifier before deciding how to code:

Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). Append modifier 58 to a code when a procedure is either planned at the time of the original procedure, more extensive than the original procedure, or for therapy following a diagnostic surgical procedure.

Important: Modifier 58 resets the global period, and you should not use it to report a complication that requires a return trip to the operating room.

Modifier 78 (Return to the operating room for a related procedure during the postoperative period). Use this modifier when an unplanned second procedure is related to the first and it requires a trip to the operating room.

Unlike 58, modifier 78 does not reset the global surgical period. It is also often appended to procedures that result from complications that occur during the postoperative period, "but it's not a hard and fast definition," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. 
 
"The CPT definition does not limit its usage to complications," Jandroep says.

Forget Modifiers and Forego Reimbursement

You should not append any modifiers to the incision and drainage code (28003) because it's the first procedure, Jandroep says, and "you only put 58 or 78 on if the patient's already in a global period. And they're not in this case, if they just had a consult."

Because the surgeon's consult led to his decision to perform surgery, you should append modifier 57 (Decision for surgery) to 99252.

As for the two returns to the OR following the I&D, you should forego modifier 78 and stick with 58.
 
Surgical modifier rationale: "In this case, because it clearly sounds as if both the amputation and secondary closure were planned, I would use the 58," says Julie Wagner RHIT, CCS-P, coder at Fond du Lac Regional Clinic in Wisconsin.
 
In the case of the first return to the OR, "It sounds as if the amputation was inevitable and the surgeon was just waiting for the infection to resolve," Wagner says. "The secondary closure was also clearly planned because a person can't really walk around with an open wound.

"I tend to use the 78 more for complications that  require returning to the OR," Wagner says. "The use of the 78 usually also results in a significant payment reduction which the 58 is not subject to."

Solution: Based on the above information, you should code the claim as 28003, 99252-57, 28820-58, 13160-58.

Rule of thumb: Many coding experts advise only using modifier 78 if the first surgery necessitated the second. For example, if a postoperative infection causes the patient to require a second visit to the OR, coders would append 78 instead of 58. In our example, the patient needed the amputation because of the underlying infection, not because of the I&D.

Remember: "The use of these modifiers really depends on the documentation," Wagner reminds coders, so don't claim the services unless the surgeon's documentation supports them.