Pulmonology Coding Alert

Unmask the modifier to use when describing treatment for complication.

Global period modifiers can leave you perplexed if you don't know when to append them for the added service. Because some modifiers share the phrases "same physician," "postoperative period," and "related procedure," many coders often let their usage of modifiers go awry.

Check out the following two frequently asked questions (FAQs) to help you ease through the subtleties of applying these modifiers.

1. What Is The Difference Between Modifier 58 And 78?

According to CPT guidelines, you would use modifier 58 (Staged or related procedure or service by the same provider during the postoperative period) when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was:

• planned or "staged" or
• more extensive than the original procedure; or
• for therapy following a surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

When you have to deal with modifier 58, make sure the physician documents each stage of the surgery and your plans for returning the patient to the operating room for additional procedures to manage the patient's condition. This modifier only applies to procedures with postoperative periods.

The global period restarts with reporting the second (subsequent) procedure and modifier 58. Assuming your coding was accurate, the surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures. Avoid common coding errors involving the inappropriate use of this modifier with services that do not have a postoperative period, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Example 1: A surgeon performs bronchoscopy on a patient for diagnostic purposes. The scope reveals the patient has a lobar foreign body obstruction. The surgeon recommends thoracic surgery, but first, attempts to remove the foreign body bronchoscopically. After the attempt fails, the surgeon then plans to perform thoracotomy. In this case, you may report the failed diagnostic bronchoscopy separately using 31635 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of foreign body) appended by modifier 53 (Discontinued procedure). You do not need to append modifier 58 to the appropriate thoracotomy code (for example, 32151, Thoracotomy, major; with removal of intrapulmonary foreign body) if the thoracotomy is not carried out on the same date since the bronchoscopy does not have an associated postoperative period.

You should not use modifier 58 to describe treatment for a complication. The follow-up procedure should arise because of the same condition that prompted the initial procedure, never a different condition. When a patient returns to the operating room for complications, you should instead append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the follow-up procedure.

Modifier 78's descriptor indicates that another (unplanned) procedure, which requires the use of "an operating room" (or any procedural suite such as a bronchoscopy suite), was performed during the postoperative period of the initial procedure. Remember, in contrast to modifier 58, modifier 78 usage does not trigger a new global period. In the case of bronchoscopic procedures, you would use this modifier when two qualifying services are performed on the same date, Pohlig explains.

Example 2: The pulmonologist performs a direct laryngoscopy with biopsy and removes multiple specimens (31535, Laryngoscopy, direct, operative, with biopsy). A few hours later, the patient goes into respiratory distress. This time the physician performs an emergency tracheostomy (31603, Tracheostomy, emergency procedure; transtracheal) in the operating room to bypass an edema that is obstructing the patient's airway. The patient's respiratory distress is related to  the original procedure because the removal of multiple specimens caused a laryngeal edema that closed the throat. The laryngoscopy has a zero-day global period, but any procedure performed on the same day is included in modifier 78 guidelines. Because the tracheostomy requires a return to the operating room, you would report it separately by appending modifier 78 to 31603.

2. What Impact Does Modifier 78 Create On Reimbursement?

Essentially, you should keep in mind that modifier 78 creates an impact on your reimbursement. For instance, modifier 78 results in a decrease in reimbursement based on the portion of the fee assigned to the "postoperative" portion of the case. For Medicare claims, you should expect a reduction of anywhere from 15-30 percent on your reimbursement. The surgeon is only paid the  intraoperative allowance attributed to the fee schedule since they are considered to have already been paid for the preoperative and postoperative portions, given that the global period stays consistent with the original surgery, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Other payers may use a different percentage.

Don't forget: Modifier 78 should always be used for Medicare carriers in appropriate situations. Don't use modifier 78 when the patient's condition requiring additional surgery is unrelated to the original surgery, as this warrants appending the modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Also, appending modifier 78 to a subsequent procedure ties the global period to the initial procedure. For example, if the global period finishes 90 days from the initial procedure, this means reporting follow-up care for reimbursement would begin 90 days from the initial procedure, not the subsequent procedure. (For a sample modifiers 58, 78 applicability and impact table guide, email editor Claire Gamboa at cgamboa@codinginstitute.com.)