Part B Insider (Multispecialty) Coding Alert

Hint: Know the nuances between modifiers 59, 78, and 79.

Choosing the correct modifier can be a challenge, and the wrong choice can trip up your Part B claims. That’s why it’s critical you know which modifier to pick when your surgeon performs a procedure during the postoperative period.

Read on for our expert advice to help you achieve appropriate pay in these post-op puzzles.

Tip 1: Meet 3 Requirements for 78

Sometimes your surgeon will need to return a patient to surgery during the postoperative period. You must identify those situations by using the appropriate modifier to alert payers that the procedure “has been altered by some specific circumstance but not changed in its definition or code,” according to CPT^® instruction.

Modifier 78: You’ll turn to 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 same surgeon, or a surgeon in the same practice and specialty, returns a patient to surgery and meets the following three special circumstances:

• The subsequent procedure falls within the global period of the initial surgery;
• The surgeon returns the patient to the operating room (OR); and
• The subsequent procedure is related to the initial surgery, such as a complication, but is not planned as a second part of the initial surgery.

Memory aid: “I use the rhyme 78-relate, and that pretty much says it all,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. Use modifier 78 if the patient requires a return trip to the OR that is directly related to a procedure that took place within the past 90 days, she says.

Caution: If the surgeon performs an unplanned procedure during the global period at the bedside or office instead of the OR, the global period includes the service and you shouldn’t use modifier 78.

Tip 2: Don’t Confuse 78, 58, and 79

If your surgeon performs a planned procedure in the post-op period, or one that isn’t related to the initial procedure, you don’t meet the 78 criteria and will have to use a different modifier.

“Often the quandary is whether the service was planned/ staged or unplanned, but related,” Hauptman says.

If the surgeon performs a planned related procedure, such as an anticipated second stage of the initial procedure, you should not use modifier 78. Instead, you should turn to modifier 58 (Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period).

Modifier 79: Unlike procedures you would modify with 78 or 58, some cases require that you append 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). The second procedure, the one with modifier 79, is unrelated to the initial procedure, explains Gregory Przybylski, MD, at the JFK Medical Center in Edison, New Jersey.

If the procedure is totally unrelated to the procedure within the last 90 days, you should use modifier 79, and that would set a new global period in motion for the second procedure, Hauptman explains.

Tip 3: Brace for Payment Consequences

When you report modifier 78, you should expect less pay for the procedure than you’d get for the unmodified code.

“Modifier 78 results in reduced reimbursement because there is not a new global period,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. Pricing for CPT^® global codes includes work expected during the global period. The reduced pay applied with modifier 78 reflects the fact that only the intraoperative part of the reimbursement is compensated, Bucknam explains.

Put it all Together

Consider the following modifier 78 example:

The surgeon performs a small intestine resection for a patient with a section of necrotic bowl in the jejunum. After clamping the proximal and distal margins, the surgeon resects the involved bowl, then anastomoses the small intestine by opening an enterotomy in the proximal and distal ends.

Two days following the surgery, the patient presents with a fever and bowl tenderness. The same surgeon returns the patient to the operating room to reopen the recent laparotomy and perform a complete washout due to a peritoneal infection.

Code this: Report the first procedure as 44120 (Enterectomy, resection of small intestine; single resection and anastomosis). For the reopening and cleaning of the surgical site two days following the initial surgery, report 49002 (Reopening of recent laparotomy) with modifier 78.