Otolaryngology Coding Alert

Correctly indicating to a payer how a service or procedure is related or not to another surgery can make the difference between reimbursement for the second treatment and denial. Sorting out which postoperative modifiers apply in a certain situation, however, can prove more gray than black and white. Consider each modifier's role to determine if your "related" services knowledge stacks up.

When separately reporting postoperative services that are not included in the original procedure's global package, you must decide if the follow-up service is related to the primary surgery. Because procedures can be related in different ways, choosing the appropriate modifier can prove elusive, says Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus and head and neck practices in metro Atlanta.

For instance, modifiers -58 (Staged or related procedure or service by the same physician during the postoperative period) and -78 (Return to the operating room for a related procedure during the postoperative period) refer to related procedures. The description "return to the operating room" may tempt you to think that modifier -78 applies to secondary procedures that occur in the operating room and that modifier -58 refers to services that take place in other locations. But this division based on site of service is not correct.

The difference instead is based on whether the otolaryngologist planned or anticipated that he or she may need to perform a second procedure at the time of the initial surgery, or the subsequent surgery is more extensive. If the subsequent surgery is planned and staged, you should use modifier -58. The otolaryngologist may sometimes perform one part of a complicated surgery at one session and then finish the procedure a week later, says Jay B. Horowitz, MD, clinical assistant professor of surgery/otolaryngology at Robert Wood Johnson Medical School in New Jersey.

In this case, you must append modifier -58 to the second procedure to break the global period of the initial procedure. To use modifier -58 during the postoperative period, make sure the second procedure meets one of the following criteria:

1. planned at the time of the original procedure (staged)
2. more extensive than the original procedure
3. for therapy following a diagnostic surgical procedure.

Physicians often initially perform less extensive procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "The American Medical Association created modifier -58 in part to encourage physicians to provide the most conservative care possible leading to more drastic interventions, when necessary." Without modifier -58, doctors would have no way to recoup payment for surgeries performed during the global period that were staged or more extensive than the original procedure. "This in turn would encourage physicians to perform less conservative care," she says.

The surgical package affects modifier -58 in another way. When a physician uses modifier -58, the global period is reset and a new postoperative timetable begins, Cobuzzi says. For instance, if an ENT performs a major surgery that contains 90 global days and he performs a second staged procedure on day 80, the second surgery starts a new 90-day global period.

In contrast, modifier -78 does not trigger a new global period. Because modifier -78 almost always involves a complication from the first surgery that requires a second procedure to fix the problem, you stay within the global of the original surgery, Cobuzzi says.

For instance, if you have a return to the operating room procedure that occurs on day 80 of the original surgery's global period, you have only 10 global days left. Because the postoperative timetable doesn't reset, you get paid only for the interoperative allowance, which varies from about 70-80 percent of the procedure, Cobuzzi says.

On the other hand, if the secondary service is unrelated to the original procedure, you should use modifier -79 (Unrelated procedure or service by the same physician during the postoperative period). "This is the easiest of the postoperative modifiers to sort out," Horowitz says.

Although it's usually self-evident that a procedure is unrelated, some third-party payers may complicate the issue and have different regulations than Medicare. For instance, a private payer may consider a procedure unrelated to the primary surgery, but Medicare considers it related.

In addition, you must pay attention to the global period when applying modifier -79. If a patient requires an unrelated procedure during the postoperative period of another surgery, you should use modifier -79. "Otherwise, the payer won't pay for the second procedure the first time," Horowitz says. Once the global period expires, you no longer need the modifier. You should follow this same rule with all three postoperative modifiers.

When using these modifiers, watch your postoperative claims closely. Some insurers, such as Blue Cross Blue Shield, have software edits that automatically reject all procedures performed during the global period, Ritter says. So, she recommends contacting the provider representative to alert them to this error.