Podiatry Coding & Billing Alert

Rely on the medical record to sift between staging and unexpected complication.

Do you know what to do if your podiatrist's patient has to return for another procedure in the global period of the initial procedure? The choice of a correct global-period modifier can be the difference between a well-deserved payment or a claim rejection, or even worse, an audit with an unhappy outcome. Follow these three expert tips to make sure you pick the right modifier every time.

Background: You have two commonly used modifiers for postoperative procedures. However, while one modifier resets the global period, the other does not, thus leading to two totally diverse results.

You should use these modifiers with caution as they have similar definitions:

• 58 -- Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period 

• 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.

Tip 1: Reserve 58 for 'Planned' or 'Staged' Revisit

CMS guidelines stipulate that you should attach modifier 58 when a subsequent procedure in the postoperative period of the first procedure is:

• planned or "staged" or

• more extensive than the original procedure; or 

• for therapy following a diagnostic surgical procedure; or

• for the reapplication of the cast within the 90-day global period.

A common pointer is that you can safely use modifier 58 when the need for the follow-up procedure arises because of the same condition/problem that prompted the initial procedure. Whether planned or not, the second procedure may be construed as the second part of the complete treatment for the diagnosed condition. Although your physician will document each stage of the procedure, including plans for returning the patient to the operating room for additional procedures, he may not exactly spell out the plan in the records.

Hint: You should automatically think of modifier 58 if the medical record shows that the podiatrist anticipated a subsequent surgery or procedure. You should keep a keen eye out for hints of the physician's decision to recall the patient during the initial procedure itself or after he knows the outcome of the surgery and the status of the patient.

For example: A patient has a grossly infected foot wound (heel). The physician may have to perform a partial foot amputation, using VAC therapy (KCI) and subsequently take the patient back to the OR for a definitive wound closure. Since a foot amputation carries a global period of 90 days, you would need to use modifier 58 to allow for reimbursement of the second procedure (wound closure).

Hit the reset trigger: The global period is reset when you report the second (subsequent) procedure with modifier 58.

Tip 2: Use 78 for Complications

You cannot use modifier 58 to describe treatment for a complication during the global period. You should append modifier 78 instead of 58 when the patient requires an unplanned return to the operating room (OR) due to a complication. A complication means an unexpected and different condition than the problem that prompted the original surgery. Even if the follow-up procedure is planned but is for a separate condition/problem from that of the initial procedure, you should append modifier 78 to the follow-up procedure.

You cannot claim modifier 78 for every unplanned revisit. Unlike modifier 58, a visit to the OR is necessary for appending modifier 78. Many Medicare payers may consider non-OR office visit such as to clean and dress a minor infection at the wound site as part of the original procedure's global package.

Caution: You should use modifier 78 only when the patient's condition requiring a second procedure is related to the original condition or is a complication of the original surgery. Otherwise, you would be better off using modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) for unrelated revisits.

Tip 3: Prepare for Payment Difference

Be ready for payment differences between the two modifiers because of one significant rule -- Resetting of the global period. As modifier 58 will trigger global period restart, your physician is eligible for 100 percent reimbursement on both the initial and subsequent procedures.

This is not the case for modifier 78. You should expect lesser reimbursement because payment based on the portion of the fee assigned to the "intraoperative" work. In other words, the surgeon doesn't receive pay for the pre-op and post-op work for the second surgery, because it's still part of the original global period. For Medicare claims, you should expect a reduction of anywhere from 15-30 percent of your reimbursement.

Watch global days: You should make doubly sure of the global days available to you before billing the modifiers. This is due to the reductions in global days for many procedures from 90 to 10 or even to 0. If you use modifier 78 for a return to the OR for a complication after a procedure performed via one of those approaches, you are likely inappropriately reducing your reimbursement. You should also avoid a common coding error involving the inappropriate use of modifier 58 with services that do not have a postoperative period.