Radiology Coding Alert

How to collect for services you perform during the global period

If your interventional radiologist performs additional procedures during a patient's global period, you can collect extra reimbursement if you append modifiers -58,  -78 or -79 to the procedure code. But first you must determine whether the patient returns to the operating room, and whether the secondary procedure is related to the original surgery.

The following five tips can help your practice decide which modifier best fits your claim.

Tip 1: Append Modifier -58 for Related or Anticipated Procedures

Modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) applies if your postoperative service meets one of the following criteria:

When the physician performs the first procedure, he determines that he will have to perform an additional procedure during the global period.

The second procedure is more extensive than the original procedure.

The patient must return for therapy following a diagnostic surgical procedure.

Rationale: In each case, the subsequent procedure is either related to the underlying problem or diagnosis that prompted the initial surgery, anticipated when the surgeon performs the first procedure, or both, says Sharon Tucker, CPC, president of Seminars Plus, a Fountain Valley, Calif., consulting firm specializing in coding, documentation and compliance issues.

In other words, the patient's condition, rather than prior surgical results, dictates the need for additional procedures, Tucker says. You should not append modifier  -58 if the patient requires a follow-up procedure due to surgical complications or unexpected postoperative findings that arise from the initial surgery.

Example: The interventional radiologist places a percutaneous transhepatic catheter for biliary drainage. Due to the patient's infection, the physician cannot place a necessary stent, so he plans to perform stent placement four days after the catheter placement.

Because 47510 (Introduction of percutaneous transhepatic catheter for biliary drainage) carries a 90-day global period, the patient's carrier will deny the stent placement four days postsurgery, unless the practice appends modifier -58 to the stent insertion code.

The interventionalist should report CPT 47510 for the first procedure and 47511-58 (Introduction of percutaneous transhepatic stent for internal and external biliary drainage) after he inserts the stent. And, the operative report should reflect the reason for the staged procedure, such as biliary sepsis.

Tip 2: If It's a Complication, Turn to -78

Unlike modifier -58, you should append modifier -78 (Return to the operating room for a related procedure during the postoperative period) when reasons related to the original surgery (such as postoperative complications) cause the radiologist to perform a related procedure.

Example: The interventional radiologist surgeon places a gastrostomy tube 43750, Percutaneous placement of gastrostomy tube). Eight days later, the tube leaks, and the radiologist returns the patient to the operating room to change the tube.

Coding fix: Because 43750 carries a 10-day global period, the interventional radiologist must append modifier -78 to 43760 (Change of gastrostomy tube) for the second procedure.

Tip 3: To Append -78, the Patient Must Return to the OR 

To report modifier -78, you must ensure that the interventional radiologist had returned the patient to the operating room or procedure suite.

Medicare considers any initial surgery complications that the physician treats in an outpatient setting (such as infection, bleeding or perforation) as part of the initial procedure's global period reimbursement. In our example, the interventional radiologist returned a patient to the operating room to change his gastrostomy tube, therefore warranting modifier -78.

Tip 4: Append Modifier -79 for Unrelated Procedures

Suppose the interventional radiologist places an inferior vena cava (IVC) filter due to deep venous thrombosis (453.8). Thirty days later, the patient has kidney failure, and the radiologist inserts a tunneled catheter for dialysis. The surgeries aren't related, so no modifiers are necessary, right?

Wrong. Because the IVC filter placement has a 90-day global period, the insurer will bundle the dialysis catheter placement into the original procedure's reimbursement, unless you append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the second procedure code.

Coding solution: Therefore, you should report 37620 (Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intra-vascular [umbrella device]) and 75940 (Percutaneous placement of IVC filter, radiological supervision and interpretation) for the first procedure.

You should submit 36565-79 (Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump [e.g., Tesio type catheter]) for the second procedure, along with imaging guidance, if the physician performs and documents it.

Tip 5: If Modifier Choice Isn't Clear-Cut, Ask the Physician

Suppose the radiologist performs two thrombectomies (36870, Thrombectomy, percutaneous, ateriovenous fistula, autogenous or nonautogenous graft [includes mechanical thrombus extraction and intragraft thrombolysis]) 50 days apart. Both operative reports state, "Thrombosed hemodialysis graft." Does this warrant modifier -78 or -79?

"Thrombectomy patients sometimes restenose within the 90-day global period," says Donna J. Richmond, RCC, CPC, radiology coding specialist at Acadiana Computer Systems Inc., a medical billing management company based in Lafayette, La. "The angiography suite is considered a 'return to OR,' but there is some difference of opinion on whether to use modifier -78 or -79 on the second set of procedures."

Some consultants say that unless the stenosis occurred at the same spot as the first, the procedures are unrelated, thus warranting modifier -79. "Others say that the second procedure is still within the graft/draining veins, so it is related, warranting -78," Richmond says.

The bottom line: "Talk it over with your radiologist, give him the definitions of the two modifiers and let him make the decision," Richmond says. "After all, he's the one who's going to have to defend his coding in the event of an audit."