Orthopedic Coding Alert

Question: A patient reports with “double crush syndrome”; a diagnosis of a right C6 radiculopathy related to a C5-6 disc displacement is made, as well as the possibility of carpal tunnel syndrome (CTS). The more proximal condition is treated first with an anterior cervical discectomy and interbody fusion with structural allograft. At the first postoperative visit a few weeks later, the patient reports resolution of the arm symptoms but continued numbness and pain in the hand involving the first three digits. An electromyography (EMG) reveals CTS. A CT release is performed one month after the anterior cervical discectomy and fusion.

How should I report these surgeries?

Answer: You’ll use modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) when a different condition(s) is surgically treated within the global period of the first procedure. Check out this coding breakdown:

Initial surgery: Report 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/ or nerve roots; cervical below C2) and +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)).

Second surgery: Report 64721 (Neuroplasty and/ or transposition; median nerve at carpal tunnel) with modifier 79 appended.

Coders are often confused by which modifier to choose when the surgeon returns a patient to the operating room (OR) during the global period of another surgery. Use this quick key to learn the modifiers you’ll choose from in these instances:

• Use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) when the surgeon returns the patient to the OR for a scheduled, staged, or otherwise related surgery.
• Use modifier 76 (Repeat procedure or service by same physician or other qualified health care profes­sional) when the surgeon returns the patient to the OR to repeat the same surgery. This is not for use if a different surgeon performed each surgery.
• Use modifier 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) when the surgeon returns a patient to the OR for a surgery that is an outgrowth of the original surgery, not the original condition.

Further, modifier 78 has two caveats attached to it:

• The patient must be returned to the OR (or an endoscopy suite) for the surgery to qualify for the 78 modifier.
• The reason for the subsequent surgery must be related to the original surgery.