Orthopedic Coding Alert

Don’t shortchange your “return to the OR” fee.

When complications from an initial procedure cause your orthopedic surgeon to perform a follow-up procedure for a Medicare patient, you may be able to report the followup separately.

How? If the follow-up procedure was serious enough that the orthopedic surgeon had to perform it in an operating room (OR) or suite (hospital or ambulatory surgical center), you may be able to get paid (partially) for it by using modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

Take note: To use modifier 78 correctly, you must be sure your orthopedic surgeon performed the second procedure at the proper place of service. You need to know which types of services are part of your payer’s global package and which ones aren’t, or you might over-report on a claim. You also need to know the global period for the initial procedure.

Things Getting Complicated? Think 78

If your orthopedic surgeon treats a patient during an earlier procedure’s global period, keep your eyes peeled for modifier 78 possibilities.

If a subsequent procedure is related to the first procedure and requires a return to the operating or procedure room, modifier 78 may be appropriate.

Example: A patient had a severe hip joint infection after total hip arthroplasty (27130, Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft). The surgeon returned the patient to the operating room for hip arthrotomy during the arthroplasty’s global period. You should append modifier 78 to the arthrotomy code, 27030 (Arthrotomy, hip, with drainage [e.g., infection]).

ICD-10 tip: Don’t ignore your diagnosis coding. The reason for the return to the operating room is not the same as the reason for the original surgery. For infection, for instance, you should link an appropriate diagnosis, such as T84.52XA (Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter) to the procedural code and follow the ICD-10 instruction to report an additional code to identify the infection.

And remember that the global period stays with the original case. Payers will not “reset” the global period when you report a procedure with modifier 78, experts say.

So if a complication occurs 20 days into a 90-day global period, only 70 global days remain after the return to the operating room.

Warning: Modifier 78 is only for complications of the initial surgery requiring a return to the OR. If your orthopedic surgeon can handle the complication without heading to the OR, the service is part of the initial surgery’s global period for Medicare patients.

Example: Several weeks following flexor pollicis longus tendon repair (26370, Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon), the patient shows signs of infection along the suture line during a follow-up visit in the office. The surgeon inspects and cleans the wound, changes the patient’s dressings and administers antibiotics. You should include this in-office visit in the global package.

Expect Reduced Payout on Modifier 78 Claims

When you file a claim with modifier 78 on a second procedure, you’ll likely only collect a portion of the procedure fee.

Think of surgical reimbursement as a triangle split in three parts:

1. preoperative

2. operative

3. postoperative.

With modifier 78, you only receive operative payment because you already received pre- and postoperative payment with the original surgery’s fee.

How much will a payer pay? Rules vary, but often you-ll see roughly 80 percent of the code’s total fee.

That does not mean you should cut 20 percent from your claim’s fee, however. When using modifier 78, report your normal amount and allow the carrier to adjust the reimbursement rate.

Benefit: Letting the insurer reduce your payment slashes the chances of your fee being reduced twice.