Podiatry Coding & Billing Alert

Modifiers hold the key to payment within procedures' global periods.

Many podiatry procedures have 90-day global periods, but do you know what to do when your podiatrist sees a patient for a complication? The key is to sort through your potential modifiers.

Heads up: You should include any care your office provides within that global period in the payment for the procedure. You won't have much room to maneuver when coding for visits related to complications - unless they lead to new problems or a return to the operating room.

If your office sees a patient for an evaluation and management (E/M) visit for a complication from the original procedure, you will not find any modifier that will allow for payment if the patient is still within the global period.

But, of course, you will have exceptions.

Use Modifier 24 on E/Ms For Unrelated Problems

The only E/M modifier you can use during a global period is modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), which is applicable when the E/M is for a problem unrelated to the one for which the patient is in the global period.

Example: The podiatrist sees a patient in the office for an ingrown toenail of the right first toe medial border and the section of toenail is removed surgically. There is a 10-day global on this procedure.

The patient returns a week later for surgical follow-up and there is appropriate healing of the toenail with no complication, but the patient now complains of pain in the left heel. The physician performs a workup, orders x-rays, and a diagnosis is made of plantar fasciitis. The patient is treated with a prescription for an anti-inflammatory and given a referral for physical therapy (99213 [Office or other outpatient visit for the evaluation and management of an established patient...]-LT-24).

This would now allow for an E/M visit with use of modifier 24.

Modifier 58 Applies to Planned Procedures

The exception to the global period rule is the use of modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period), which indicates procedures during the global period that one plans (staged procedures), procedures that are more extensive than the original procedure, and for therapy following a surgical procedure.

For instance: A diabetic patient presents with a 2cm ulcer on the plantar surface of the left foot under the second and third metatarsal head. Imaging shows second metatarsal osteomyelitis, and the podiatrist takes the patient to the OR for surgery for wound debridement with excision of the second metatarsal head. The wound is packed open and will be closed at a later date.

Two weeks later, the patient returns to the OR for debridement of the wound and closure with a full thickness skin graft (13160-58, Secondary closure of surgical wound or dehiscence, extensive or complicated).

Because this was a planned return to the OR, code for this procedure with a 58 modifier.

Use Modifier 78 for Related, Unplanned Procedures

If the podiatrist performs an unplanned procedure, you should consider the procedure only billable if you perform the procedure in an operating room and use modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualifiedhealth care professional following initial procedure for a related procedure during the postoperative period). Do not bill procedures related to the problem for which the patient is in a global period (even a debridement of this post-op infection site) if the procedure occurs in the office.

Example: A patient had surgery for an elongated second metatarsal at the ASC. The surgery consisted of an oblique distal osteotomy with single screw fixation.  This has a 90-day global period.

The patient is seen at weekly intervals with no complication after two weeks. At the third visit, an x-ray is taken. The podiatrist notices that the osteotomy is displaced and the screw has pulled out.

When questioned, the patient states he slipped on a step two nights ago. The physician decides to take the patient back to the operating room at the ASC to remove the screw, realign the osteotomy, fixate the bone, and immobilize the patient in a BK cast (28322 [Repair, nonunion or malunion; metatarsal, with or without bone graft [includes obtaining graft]-LT-78).

In this case, you can use modifier 78 because this was unplanned and not part of the normal healing process.

Use Modifier 79 for Unrelated Inpatient Procedures

The only modifier appropriate for procedures performed in the office during a global period would be modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period), which is for procedures unrelated to the one for which the patient is in the global period.

Example: The patient has been treated with an oblique distal osteotomy with single screw fixation. The patient slipped on a step two nights ago, twisting and fracturing his ankle with displacement of the fibula. It is necessary to take them to the OR to surgically align and fixate the fracture (27792 [Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed]-LT-79.

In this case, you can use modifier 79. The reason is this is unrelated to the original problem but within the global period of the original surgery.