Otolaryngology Coding Alert

Must for modifier 78: The subsequent procedure should be directly associated with the initial surgery.

Global period modifiers 58 and 78 can leave you perplexed if you don't know when to append them for the added service. Because modifiers 58 and 78 share the phrases "same physician," "postoperative period," and "related procedure," many coders often let their usage of both modifiers overlap.

Check out the following basic guides to help you ease through the subtleties of applying these modifiers.

Guide 1: Draw A Clear Line Between Both Modifiers

According to CMS guidelines, you would use modifier 58 (Staged or related procedure or service by the same provider during the postoperative period) when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was:

• planned or "staged" or
• more extensive than the original procedure; or
• for therapy following a surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

When you have to deal with modifier 58, make sure the physician documents each stage of the surgery and your plans for returning the patient to the operating room for additional procedures to manage the patient's condition. However, the planning does not necessarily have to be laid out in the documentation, as in the case when a more extensive procedure is performed, therapy following a surgical procedure or for the reapplication of a cast in the global day period as outlined in the last three bullets above, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

The global period restarts with reporting the second (subsequent) procedure and modifier 58. Assuming your coding was accurate, the surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures.

Example 1: The otolaryngologist performs a biopsy of tongue (41100, Biopsy of tongue; anterior two-thirds). The pathology report, which returns a few days later, indicates the presence of a malignant tumor. The otolaryngologist then decides to excise the tumor (41120, Glossectomy; less than one-half tongue). When you bill the glossectomy, you would append modifier 58 to 41120 to indicate a staged procedure that should not be included in the biopsy's 10-day global period.

Extra: You would consider the glossectomy staged and anticipated (although not preplanned) because the otolaryngologist would not have done it had the biopsy came out negative. Additionally, the biopsy, which led to the glossectomy represented conservative care leading to more extensive, radical care, as outlined in the second bullet above.

You should not use modifier 58 to describe treatment for a complication. The follow-up procedure should arise because of the same condition/problem that prompted the initial procedure, never a different condition/problem. When a patient returns to the operating room for complications, you should instead append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the follow-up procedure.

Modifier 78's descriptor indicates that another (unplanned) procedure, which requires the use of an operating room, was performed during the postoperative period of the initial procedure. Unlike modifier 58, modifier 78 is used when the surgery is bringing the patient to the OR for a problem different from that which prompted the original surgery. Remember, in contrast to modifier 58, modifier 78 usage does not trigger a new global period.

Example 2: An otolaryngologist performs a radical neck dissection. On Day 4, he notices that the patient has a deep abscess in the neck wound. As a result, he has to bring the patient to the OR to perform the I&D. You would code this scenario as follows:

• Day 1: 38724 (Cervical lymphandectomy), 195.0 (Malignant neoplasm of head and neck)
• Day 4: 21501-78 (Incision and drainage deep abscess or hematoma soft tissues of neck or thorax), 998.59 (Other postoperative infection, abscess).

Guide 2: Expect Modifier 78's Impact On Reimbursement

Essentially, you should keep in mind that modifier 78 creates an impact on your reimbursement. For instance, modifier 78 results in a decrease in reimbursement based on the portion of the fee assigned to the "intraoperative" portion of the case. For Medicare claims, you should expect a reduction of anywhere from 15-30 percent on your reimbursement. The surgeon is only paid the interoperative allowance attributed to the fee schedule since they are considered to have already been paid for the preoperative and postoperative portions, given that the global period stays the consistent with the original surgery, clarifies Cobuzzi. Other payers may use a different percentage.

Since only the interoperative portion of the fee is paid for a 78 modified surgery, appending modifier 78 to a subsequent procedure ties the global period to the initial procedure. In the second example, the global period finishes 90 days from the neck dissection (38724). This means reporting follow-up  care for reimbursement would begin 90 days from the date the initial procedure was performed, not the subsequent procedure. (For a sample modifiers 58, 78 applicability and impact table guide used by an otolaryngology practice, you may email editor Claire Gamboa at cgamboa@codinginstitute.com.)