Podiatry Coding & Billing Alert

Returning a patient to the OR? Read this before assigning a code for multi-step procedures.

When a patient presents with a severe infection, you can be dealing with several treatment steps -- and several potential snags for your coding. Test your coding savvy by reviewing this scenario and determining the correct modifiers when three separate surgeries are needed.

Scenario: An established patient with peripheral neuropathy presents with a severe foot infection. In the course of the evaluation and management, the podiatrist completes a problem-focused exam and history to determine that immediate incision and drainage is needed (28003, Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas). He then decides to wait for the infection to subside to see if any further procedure is necessary.

Four days later, the podiatrist determines that he needs to further excise bone from the second and third metatarsals (28122, Partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus). The wound is left open for one week to drain the infection before the podiatrist performs a secondary closure (13160, Secondary closure of a surgical wound or dehiscence, extensive or complicated).

Your task: Decide what modifiers will unlock payment for these procedures.

Don't Forget Your E/M

Before deciding on appropriate modifiers for the excision and secondary closure, you want to make sure you've covered all your bases coding the initial patient encounter.

If you just reported 99212 for the E/M along with 28003 for the I&D, you'd be inviting a denial. You must append modifier 57 (Decision for surgery) to the E/M code to let your carrier know that the visit comprised a separately identifiable service, and not just a pre-op screening.

Remember to check your global: If the podiatrist performed an I&D for just one bursal space (28002), the 10-day global period of that procedure would guide you into appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). However, the 90-day global of 28003 identifies it as a major surgery, requiring modifier 57.

"The 57 modifier also applies to E/M codes done the day before the major procedure," notes Joseph Lamm, office manager with Stark County Surgeons, Inc. in Massillon, Ohio. "This is true provided that the E&M code is significant and separately identifiable."

Consider Your Options: Planned or Unplanned?

When you deal with several related procedures, the situation will generally fall into two categories. Deciding which situation best fits your specific case will also determine which modifier you use.

• Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). Use modifier 58 when a subsequent procedure is already planned at the time of the original procedure, more extensive than the first procedure, or for therapy following a diagnostic surgical procedure. Often, your surgeon will document each stage of the surgery, including plans for returning the patient to the operating room for additional procedures to manage the patient's condition. However, the planning does not necessarily have to be laid out in the documentation, according to Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.
• 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). Append modifier 78 when an unplanned procedure is related to the first. Most commonly, it is used for procedures that address unanticipated complications resulting from the initial procedure.

Rule of thumb: Many coding experts advise only using modifier 78 if the first surgery necessitated the second. For instance, if a postoperative infection causes the patient to make a return trip to the OR, you would append modifier 78. But in this case, it is the underlying condition of the infection, not the initial I&D, that makes the excision and secondary closure necessary.

Therefore, you should append modifier 58 to 28122 and 13160. Remember: The initial procedure does not require any modifiers, because it does not occur within the global period of another surgery.

Important: When you use modifier 78, you can expect a significant reduction in reimbursement. The insurance companies will pay you an "intraoperative allowance," or a surgical fee that excludes the preoperative and postoperative care allowance. The global period does not reset, however. When you append 58, you will get paid the whole surgical fee, but the global period is reset with each procedure.

Deciding which modifier to use may also depend on documentation. The best key for modifier 58 is to get as much documentation as possible of a plan, preferably before the initial surgery, experts advise.

Example: In this case, the podiatrist may not have known the exact severity of the infection after the initial office visit. Creating a plan that detailed likely treatment steps would assist coders and build strong support for appending 58. Even without this documentation, you should still look to modifier 58 if you can demonstrate that the podiatrist moved from conservative to more radical care.

Putting it together: Based on the information, you should code this case as 28003, 99212-57, 28122-58, 13160-58.