Part B Insider (Multispecialty) Coding Alert

Question: Our physician performed a spinal procedure during the global period of a different spinal surgery. Which modifier applies?

Answer: The answer may depend on whether the second surgery was a result of a complication from the first surgery or if it was because the first surgery did not provide the desired outcome.

If the first surgery did not achieve the desired outcome, even if the second surgery was not planned, it is still staged, to get the original desired outcome, and so modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) would be appropriate. The diagnoses used would be the original diagnoses for the first surgery because the surgeon is treating the original problem that was not resolved as he had hoped with the first surgery. The second surgery is related, but staged because the outcome was not realized.

But if the first surgery had achieved the outcome as planned, but there were complications, your coding options would be different. If the patient had to be brought back to the OR to treat the complications, the diagnosis would be different than the original surgery's diagnosis because you would use the ICD-9 code for the complication. In this case, you'd append 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).

Bottom line: If you are treating a complication that occurred as a result of the first surgery, you'll use the 78 modifier. If you are treating the original reason you needed to do surgery in the first place (for the first surgery), you should be using the 58 modifier.