Part B Insider (Multispecialty) Coding Alert

Beware:  Don't charge separately for procedures in outpatient settings

When your surgeons perform an initial surgery, there’s a good chance that they will have to perform a second surgery. Here’s why you should rely on modifier 78 to properly document an additional surgery necessitated by circumstances arising from the first.
You should think of modifier 78 as the “complications” modifier, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, FL. You can apply modifier 78 (Return to the operating room for a related procedure during the postoperative period) under the following circumstances:
• the surgeon must undertake the subsequent surgery because of conditions arising from the initial surgery;
• the subsequent surgery occurs during the global period of the initial surgery; and
• the subsequent surgery requires a return to the operating room (OR).

Example: Several days following hernia repair (49560, Repair initial incisional or ventral hernia reducible), the patient develops an infection at the incision site. To treat the infection, which has become fairly serious, the surgeon returns the patient to the OR for debridement (11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface).
Important: For Medicare carriers, you cannot charge separately for complications that the surgeon handles in an outpatient setting. These could include infection, bleeding or perforation, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, NE. Such services are covered under the surgery’s global period, according to the Medicare guidelines .
For instance, the patient in the example above develops a minor infection at the site of the surgical wound. In this case, the surgeon simply cleans and dresses the wound in his office. In this case, the global surgical package of the original procedure (that is, the hernia repair 49560) includes the uncomplicated follow-up care.