Orthopedic Coding Alert

Unplanned postop procedures separated by OR question.

When the surgeon needs to perform an unplanned procedure during a patient’s postoperative period, coders need to be ready to choose between a pair of modifiers to make sure the claim is compliant.

The lowdown: Modifiers 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) and 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) will help you lock down any reimbursement your practice deserves for certain unplanned postop services. How effectively you can deploy these modifiers will depend on the knowledge you bring to the table.

Don’t worry, though. We’ve got experts to lead you through a primer on these two modifiers to help you through your unplanned postop procedure coding.

If Procedure Relates, Use 78

One coding expert has made an easy mnemonic device out of modifier 78, and it help explains when to use it.

“I use the rhyme 78-relate, and that pretty much says it all,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “If a patient requires a return trip to the OR [operating room] that is directly related to a procedure that took place within the last 90 days, the 78 modifier is appended.”

There are several instances in which you might use modifier 78, but the important elements of each encounter are whether the service was related to the original surgery and whether or not the surgeon returned the patient to the OR.

“Often the quandary is whether the service was planned/staged or unplanned, but related,” explains Hauptman. “A staged procedure would be a 58 modifier [Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period], while the 78 is for that unplanned trip. Keep in mind that it must be trip to the OR. If another procedure is needed and performed at the bedside or in the office, it cannot have the 78 appended to it as it is included in the global surgical package.”

Coders can expect reduced payment for any modifier 78 claims, experts say.

“Modifier 78 results in reduced reimbursement because there is not a new global period; only the intraoperative part of the reimbursement is paid,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Some situations in which modifier 78 might come in handy include:

• Postoperative hematoma treatment related to surgery.
• Skin/wound issues related to surgery.
• Dislocation of total hip arthroplasty (THA).
• Displacement or breakage of orthopedic implant.

Unrelated Procedure in Postop Window Gets 79

As 78 is for related procedures, modifier 79 “is for procedures performed that are unrelated to the one performed within the last 90 days [the original global surgical period],” says Hauptman. “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.”

Unlike modifier 78, the payment for modifier 79 is the full global reimbursement, according to Bucknam.

Know this: “It’s important to remember that the second procedure, the one with modifier 79, is unrelated. It’s not a planned return for a staged procedure or a return to the OR for a complication or other related procedure.”

Bucknam says that modifier 79 isn’t used a great deal, but a common 79 scenario involves surgery to treat bilateral carpal tunnel syndrome (CTS). Typically, the surgeon would not treat both arms at the same time “because of the difficulties related to having both arms disabled during healing,” Bucknam explains. If the surgeon treats the second wrist during the global period of the first surgery, then modifier 79 is appropriate for the second CTS surgery.

Another modifier 79-appropriate scenario might involve a patient who is in the postop period for arthroscopic shoulder surgery who falls and fractures his leg. Care of the leg is unrelated to the global period created by the shoulder surgery, and therefore any procedure for the leg that you code would need modifier 79.

Remember ICD-10 Codes, Documentation to Cement Claims

No matter the modifier, you’ll need to have solid documentation of each of the patient’s conditions to make both 78 and 79 claims fly. Make sure your providers know the importance of accurate ICD-10 coding for each condition related to the encounters involved in your modifier 78/79 claims.

As far documentation outside of ICD-10 codes for modifier 78 claims, “the documentation should clearly indicate the relative nature of the procedure. The physician should be very clear when talking about the second procedure in both the visit leading up to the procedure as well as the procedure itself,” explains Hauptman.

Bucknam agrees, saying “in the case of modifier 78, it’s important for the surgeon to document that the return to the OR is a complication rather than a planned or staged return. This can be difficult to determine when you read the documentation.”

As for modifier 79, “it can be helpful if the surgeon states the date of the previous surgical procedure in order to help the coder identify that there was a previous surgery, especially in a large practice,” according to Bucknam.

Remember: You’ll be able to use modifiers 78 and 79 when the global postoperative period begins, which is the day after the surgical procedure, reminds Bucknam. “If the patient returns to the OR on the same date, other modifiers are appropriate, like 59 [Distinct procedural service] or 76 [Repeat procedure or service by same physician or other qualified health care professional]. If you use modifier 78 or 79 for services on the same date as the original procedure it can cause a lot of confusion with the insurer.”

Example: If a patient has postop surgical bleeding and goes back to the OR on the same day as the original procedure, you’d use modifier 59 for the bleeding treatment. “If the same procedure is performed on a different calendar day, use modifier 78,” says Bucknam.