Orthopedic Coding Alert

Orthopedists whose patients must return to the operating room for additional treatment during the global period deserve additional reimbursement, as long as you append modifier -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period) to the procedure code. The key is determining whether the secondary procedure is related to the original procedure.

Many coders believe that modifiers -78 and -79 are interchangeable, but there are distinct differences between the two that go beyond the fact that modifier -78 refers to a related procedure and -79 refers to an unrelated service. Specifically, modifier -78 does not launch a new postoperative global period, and therefore, any service with modifier -78 appended exists within the original global period. If you append modifier -79 to a service, however, Section 4822 of the Medicare Carriers Manual (MCM) states, "A new postoperative period begins when the unrelated procedure is billed."

For instance, says Jeanne MacRae, CPC, coding specialist at Family Spine and Sports, a three-physician practice in Orlando, Fla., the orthopedist performs a total knee replacement (27447), and the patient fractures her arm 65 days later. The orthopedist should bill for the open humeral shaft fracture treatment by reporting 24515-79.

Although the patient only had 25 days left in the original global period, using modifier -79 on the claim will launch a new global period for an additional 90 days.

Suppose an orthopedist performs a repeat right knee ACL reconstruction (29888) with medial meniscectomy (29881) and a left knee patellar tendon harvest graft for the ACL reconstruction. In the recovery room following surgery, the patient falls and tears the left patellar tendon, requiring surgical repair (27380).

Many coders would question whether the patellar tendon repair is actually related to the original surgery because "related procedures" are often merely infections or other problems caused by the first procedure. The patellar tendon repair, however, results from a surgical complication and, therefore, is required as a result of the original surgery, says Paul K. Kosmatka, MD, orthopedic surgeon at the Marshfield Clinic in Wisconsin.

"If a secondary procedure is required because the patient had the first procedure, then the two services are related," Kosmatka says. "This is a great example of a second procedure that would never have been needed if not for the first procedure that is, the left patellar tendon would not have torn if not for the tendon harvest." Kosmatka suggests that if the patient fell with a normal knee, the tendon would not have torn.

The first surgery should be coded as follows: