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 [...]