Orthopedic Coding Alert

Question: Recently, a patient came to our office for a follow up after he had an arthroscopy on the knee. After observation, he had right knee arthroscopy with recurrent effusion. We started post op care and aspirated and injected the knee. I know what code to use, but given the additional procedures, should I use a modifier?

California Subscriber

Answer: You have to use either 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) or 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period), which is more likely. Below are some helpful hints about when to use each modifier.

Modifier 78 is used if the postoperative procedure was unplanned. Keep in mind that this modifier must be used if the physician performing the postoperative service is the same physician who initially worked on the patient.

Modifier 79 can be used when the postoperative procedure is unrelated to the original procedure performed by the same physician. The physician should indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. During these circumstances, you should use modifier 79, and this is therefore the more likely of options.