Urology Coding Alert

Requirements and reimbursement potential of modifiers -78 and -79

Practices can avoid forfeiting reimbursement dollars by gaining a comprehensive understanding of how global surgical packages work and the CPT codes to use when billing for services (either related or unrelated) during the period following surgery (global period).
 
You use modifiers -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) when a physician has to return a patient to the operating room (OR) for procedures during the postoperative period of another surgical procedure. These modifiers also apply when a different physician from the same professional
group, billing under the same tax ID number, treats the patient during the postoperative period.

Medicare's Globals: Minor Versus Major

Medicare categorizes the CPT surgical codes as "minor" or "major" as a way of defining their global surgical packages. Minor and major global surgical packages differ according to the number of days covered. Medicare's global package for surgical procedures constitutes 0, 10 or 90 days, depending on their assigned category.
 
Minor procedures include those procedures with either a 0- or 10-day global surgical package. Included in the minor surgical package is the visit the day of the procedure (unless it is significant and separately identifiable from the procedure), the procedure, and postoperative care either 0 or 10 days after the surgery to treat the surgical site. Visits for treatment of unrelated conditions are not included and are separately billable.
 
Major procedures have a 90-day global surgical package.  Included in the major surgical package are the preoperative visit (the day of or the day before), the operative procedure, and postoperative care for up to 90 days.
 
If the procedure is considered "minor" and an office visit is rendered on the same day, you can bill an E/M service with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), if you meet the criteria of the modifier. If the office visit service is integral to the procedure - such as a preoperative exam - you can't separately report it, because it is included in the global surgical package.
 
Against this backdrop, take a look at how modifier -78 can help you recover revenue for related services delivered in the global period.

Modifier -78: The 'Complications' Modifier

Modifier -78 refers to a "related procedure" in its description and applies when the related procedure is to treat complications arising from the initial surgery, rather than from the patient's condition. This is an important distinction that affects both coding accuracy and reimbursement. You should use modifier -78 only on procedure codes for treating complications arising from the original procedure.
 
For example, a urologist places a suprapubic catheter in the operating room several hours after a TURP, 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]), for better drainage and control of postoperative bleeding. You should code the suprapubic catheter insertion as 51010-78 (Aspiration of bladder; with insertion of suprapubic catheter).
 
Using modifier -78 on a second procedure limits payment to only the intraoperative portion of the global fee.
 
Modifier -78 requires that the patient be returned to the OR. Medicare defines the OR for this purpose as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The definition of OR may also include a cardiac catheterization suite, a laser suite and an endoscopy suite. The definition does not include a patient's room, a minor treatment room, a recovery room or an intensive care unit (unless the patient's condition was so critical that there would be insufficient time for transportation to an OR). The term  cannot also be applied for related procedures performed  in-office in the physician's exam room or minor operating room. Any complications of the initial surgery that can be handled without a return to the operating room are included in the global period of the initial surgery.    

Therapeutic services, diagnostic tests related to complications, are still billable. For example, an office uroflow is payable, but a complex catheter insertion in the office for acute urinary retention is not.
 
Modifier -79: Unrelated Procedure, Same Physician

Modifier -79 indicates that the same physician performs a subsequent surgery on a patient for a condition unrelated to either the condition that prompted the initial surgery or the surgery itself. In other words, if the same surgeon must perform a separate evaluation and undertake a distinct, unrelated surgery (including all follow-up) for a medical condition during the global period of a previous procedure, modifier -79 is appropriate.
 
For example, a patient with localized recurrent prostatic carcinoma undergoes cryosurgical ablation after failed radiation therapy. Postoperatively he does well, but after one month he requires a TUR for a bladder neck stenosis, apparently secondary to the previous radiation. A closer look at the TUR procedure reveals that this second procedure is for a problem entirely unrelated to the cryosurgical ablation of the prostate, thereby meriting the use of modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) with the appropriate TUR code, 52500-79 (Transurethral resection of bladder neck).
 
If you append modifier -79 to a service, Section 4822 of the Medicare Carriers Manual states, "A new postoperative period begins when the unrelated procedure is billed." So in the  above case, if the urologist performs the procedure 45 days into the global period from the initial cyrosurgery, the use of modifier -79 on the claim for the second surgery will launch a new global period for an additional 90 days.

Reimbursement: What to Expect

"Medicare reimburses only for the intraoperative portion of procedures billed with modifier -78. No payment is made for pre- or postoperative care," says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. "Medicare reduces the payment to about 70 percent to 80 percent of the global fee, the intraoperative portion of the surgical fee."
 
You should anticipate this fee reduction, but don't cut the fee on your claim form. Always bill your normal amount and allow your carriers to make the adjustments (don't worry, they won't forget). This will decrease the chances of your fee being reduced twice. If a procedure with "000" global days is billed with modifier -78, the full fee will be paid because such procedures have no pre-, post- or intraoperative values.
 
Medicare should not reduce reimbursement for services appended with modifier -79. Claims filed with     -79 should be reimbursed at their full value because a complete global surgical package is provided including pre-, intra- and postoperative components.
 
Many payers differ from Medicare by not requiring that the second procedure be absolutely unrelated to the initial surgery to bill with modifier -79. For office care, some carriers allow that significant postoperative complications may require enough evaluation to begin a new global period and will allow payment at full value. The result can be payment without reduction, using modifier    -79 attached to the procedure code when these procedures are performed out of the OR.

Reduction Happens

Although coding experts agree that reductions should not occur when -79 is appended, they still occasionally do. Ask your carriers which modifier they will accept in a given situation.
 
For Medicare's specific guidelines for use of modifiers during the global surgical period, look in Section 4820 of the Medicare Carriers Manual Part 3 or review the policy on-line at www.hcfa.gov/pubforms/14_car/3b4820.htm#_1_8.