Orthopedic Coding Alert

If the first procedure didn't necessitate the second procedure, look to -79

When you have trouble choosing between modifiers -78 and -79, ask yourself this question: "Would the patient have required the second surgery if the first surgery hadn't occurred?" If the answer is "no," you should turn to modifier -78 (Return to the operating room for a related procedure during the postoperative period).

Meet 3 Guidelines for -78

You should apply modifier -78 when you meet three criteria:

1. The surgeon must undertake the subsequent surgery because of complications from an initial surgery.

2. The subsequent surgery occurs during the global period of the initial surgery.

3. The subsequent surgery requires a return to the operating room (OR).

You should think of -78 as the "complications" modifier, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla.

Example: Several weeks following anterior cervical diskectomy and fusion (for example, 63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace and 22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2), the patient develops an infection at the site of the surgical incision.

To treat the infection, the surgeon returns the patient to the OR for debridement (for example, 10180, Incision and drainage, complex, postoperative wound infection). In this case, you should report 10180-78.

Bundle Procedures That Don't Require OR Visit
 
If you're billing Medicare carriers, you cannot charge separately for complications that the orthopedic surgeon handles in an outpatient setting. These could include infection, bleeding or perforation, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Such services are covered under the surgery's global period, according to Medicare guidelines.

For example: A week after surgery, the patient in the  example above develops a suture granuloma at the site of the surgical wound.

In this case, the orthopedic surgeon cauterizes the area with silver nitrate in his office. The global surgical package of the original procedure (that is, the diskectomy and fusion, 63075 and 22554) includes this uncomplicated follow-up care.

Apply -79 for Brand-New Circumstances

You should apply modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) when you meet two criteria:

1. The orthopedic surgeon must undertake the subsequent surgery for conditions unrelated to the initial surgery.

2. The subsequent surgery occurs during the global period of the initial surgery.

In other words, Jandroep says, if the same surgeon must perform a separate evaluation and a distinct, unrelated surgery - including all follow-up - for an unrelated medical condition during the global period of a previous procedure, you should append modifier -79 to the subsequent procedure code(s).

When in Doubt, Ask Physician if Injury Was Related

Example: The orthopedic surgeon performs spinal decompression 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disk], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disk]) on a 48-year-old male patient.
 
Nine weeks later, the patient falls at home and fractures his patella. The same surgeon re-evaluates the patient and performs an open reduction with internal fixation (for instance, 27524, Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair) during the global period of the initial surgery.
 
In this case, you should report the second procedure as 27524-79 to indicate that the decompression was unrelated to the initial surgery.