Otolaryngology Coding Alert

Procedures can be "related" in different ways. For example, Medicare considers treatment of a complication (e.g., wound infection) related to the original procedure. Other subsequent procedures or services may be related to the underlying condition that prompted the original surgery but are not, strictly speaking, related to the operation itself. The difference is significant from a coding perspective, because different modifiers should be used for each scenario.
 
Most procedures are part of a "surgical package" that also includes a global period, during which most additional procedures or services performed are considered part of the original procedure and not separately payable. Even procedures with zero global days (e.g., sinus endoscopies) have surgical packages, and most services provided on the day of or day before the endoscopy are included.
 
However, in many situations, services provided during the global period of another procedure are separately payable. For example, if the service provided is being performed because the patient has a separate problem that requires treatment, modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) should be appended to the appropriate CPT code when the service is reported.
 
In certain cases, related procedures may also be billed during a global period, but doing so correctly is trickier. 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) include the term "related procedure" in their descriptors. The wording of the two descriptors can misdirect coders into believing that -58 is used when a service is performed in another location and that -78 is used when the second service occurs in the operating room.
 
Although -78 requires a return to the operating room, it is distinguished from -58 in many other, more significant ways. The most important is that the two modifiers are appended to services that are "related" very differently to an earlier procedure. The difference also explains why -58 reimburses at 100 percent, whereas -78 pays only the intraoperative portion of the procedure or service performed.

Otolaryngologists often perform additional services that may be considered staged and/or more extensive procedures. CPT states that appending -58 indicates "that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure [staged]; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure."
 
Modifier -58 is a "payment" modifier, which means that it prompts the carrier's software to override any edits and pay for the service. Use of this modifier must be monitored carefully, as misuse could draw unwanted attention, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee.
 
"Modifier -58 should be used when the patient's condition requires that another procedure be performed," Eisenberg says, citing the following examples:

 

A total unilateral thyroid lobectomy is performed (60220, 90-day global period), and the pathology report returns positive. The patient returns 12 days later for a completion thyroidectomy (60260). Modifier -58 is appended to 60260.

 

A closed reduction of a nasal fracture (21230) is performed (10-day global period). The reduction is unsuccessful, so the otolaryngologist performs an open reduction (21330) five days later. Modifier -58 is appended to 21330.
 
Other examples include biopsies that later result in more extensive excisions, and repairs that require flap advancement at a later date.
 
Note: If the initial procedure has a zero-day global period and the subsequent procedure is performed on a different day, -58 is not required.

Modifier -78: Related to the Initial Surgery

When there is a complication after a procedure and another service is required, -78 is correctly appended to the appropriate procedure code.
 
For example, the otolaryngologist performs a direct laryngoscopy with biopsy and removes multiple specimens (31535). The patient goes into respiratory distress a few hours later, and an emergency tracheostomy (31603) is performed in the operating room (OR) to bypass an edema that is obstructing the patient's airway.
 
The patient's respiratory distress is related to the original procedure because the removal of multiple specimens caused a laryngeal edema to form that closed the throat. Even though the laryngoscopy has a zero-day global period, any procedure performed on the same day is included. Because the tracheostomy requires a return to the OR, however, it may be reported separately as 31603-78.
 
Modifier -78 should always be used for Medicare carriers in such situations, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wa. She notes, however, that not all private carriers follow Medicare's lead on complications.
 
"Many third-party payers still consider some complications unrelated to the original surgery," Thompson says. "When this is the case, -79 [Unrelated procedure or service by the same physician during the postoperative period] should be used instead of -78."
 
If the edema noted in the preceding example had not formed but the results of the biopsy returned positive and a more extensive excision was performed, -58 would be correctly appended to the second code, Thompson adds.
 
Another example of the appropriate use of -78 involves treatment of a postoperative bleed. Procedures such as tonsillectomy and septoplasty frequently result in postoperative hemorrhage, sometimes so serious that a return to the OR is required.
 
For example, the patient bleeds following a septoplasty (30520), and the otolaryngologist performs an internal maxillary ligation (30920). With -78 correctly appended to 30920, Medicare carriers should pay 76 percent of the 19.16 relative value units assigned to the procedure.
 
The 76 percent represents the intraoperative portion of the procedure (the actual operation). The remaining 24 percent comprises preoperative work (10 percent) and postoperative work (14 percent): These are included in the original procedure's surgical package and are not reimbursed.
 
Note: When a second procedure is appended with either -58 or -79, the global period is reset. For example, if a second, more extensive excision is performed on day 70 of the original procedure's 90-day global period, the global period is reset to a new 90-day global, Thompson says. Any subsequent procedures or services performed are included unless they too are appropriately appended with -58 or -79. This is not the case for -78. For example, if there is significant postoperative bleeding on day six of a 10-day global period and the patient is returned to the OR, the global period is not reset.