Wiki 58 or 79?? - We had a physician document

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eguest

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We had a physician document in February, 2011, he was going to perform bilateral knee replacements, the first one to be done in April, the second one done 6 weeks later, in July. So the patient was still in the global period from the first arthroplasty when the second one was performed. The insurance company denied the second one as a modifier was inadvertently left off. In appealing, should modifer 58 (Staged or related procedure) be added to the second surgery since the physician had originally documented that both would be done, or modifier 79 (unrelated procedure)since it was the opposite knee? thank you.
EGuest
 
eguest said:
We had a physician document in February, 2011, he was going to perform bilateral knee replacements, the first one to be done in April, the second one done 6 weeks later, in July. So the patient was still in the global period from the first arthroplasty when the second one was performed. The insurance company denied the second one as the surgery coder forgot to use a modifier. In appealing, should modifer 58 (Staged or related procedure) be added to the second surgery since the physician had originally documented that both would be done, or modifier 79 (unrelated procedure)since it was the opposite knee? thank you.
EGuest
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I would go with 58 for staged or related since the documentation supports that modifier.
 
eguest said:
We had a physician document in February, 2011, he was going to perform bilateral knee replacements, the first one to be done in April, the second one done 6 weeks later, in July. So the patient was still in the global period from the first arthroplasty when the second one was performed. The insurance company denied the second one as the surgery coder forgot to use a modifier. In appealing, should modifer 58 (Staged or related procedure) be added to the second surgery since the physician had originally documented that both would be done, or modifier 79 (unrelated procedure)since it was the opposite knee? thank you.
EGuest
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Oooh...this question is more complicated than I first expected! Ha!

I could be wrong about this, but my guess is 79, only because of the different body part. Yes, it was planned, and it's similar, but that doesn't make it 'related', per se. It's not like the doctor had to do one knee first and wait a given period of time, in order for the other knee's procedure to be possible/successful. (I tend to think of staged procedures in terms of skin stuff, like tissue expanders, so this doesn't really seem to fit, to me) It impacts the patient's ability to be mobile while they recover, but the 2 surgeries aren't components or stages of one another, and theoretically, they could both be done on the same day, although it's impractical for the patient. Good question, though... :)

Check here: http://www.cms.gov/manuals/downloads/clm104c12.pdf - (press Ctrl+F, then search for 58 or 79 to find the info you need.)

Hope that helps! ;)
 
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It was on page 97...

"6. Staged or Related Procedures
Modifier “-58” was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. This modifier is not used to report the treatment of a problem that requires a return to the operating room.
The physician may need to indicate that the performance of a procedure or service during the postoperative period was:
a. Planned prospectively or at the time of the original procedure;
b. More extensive than the original procedure; or
c. For therapy following a diagnostic surgical procedure.
These circumstances may be reported by adding modifier “-58” to the staged procedure. A new postoperative period begins when the next procedure in the series is billed.

7. Unrelated Procedures or Visits During the Postoperative Period
Two CPT modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure.
Modifier “-79”: Reports an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.
A new postoperative period begins when the unrelated procedure is billed."
 
eguest said:
We had a physician document in February, 2011, he was going to perform bilateral knee replacements, the first one to be done in April, the second one done 6 weeks later, in July. So the patient was still in the global period from the first arthroplasty when the second one was performed. The insurance company denied the second one as the surgery coder forgot to use a modifier. In appealing, should modifer 58 (Staged or related procedure) be added to the second surgery since the physician had originally documented that both would be done, or modifier 79 (unrelated procedure)since it was the opposite knee? thank you.
EGuest
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I think modifier 79 because even though its the same procedure but it is on the opposite knee.

SAUKA
 
This is a tough one...I was really going with the wording under Modifier 58 where it says "..(a) planned or anticipated (staged)..." since even though the procedure is on the opposite knee it is the same procedure and is was planned and anticipated to be done before the post operative period on the original knee was over. The title is "Staged or Related"..and since this was discussed and planned for in the initial preoperative stage of the first knee, and it is the same procedure just opposite side, seems like it could meet that description.

Of course the argument that 79 is better if the procedure considered "unrelated" since it was the opposite knee also works. The coder will have to decide which better fits the situation.
 
ajs said:
This is a tough one...I was really going with the wording under Modifier 58 where it says "..(a) planned or anticipated (staged)..." since even though the procedure is on the opposite knee it is the same procedure and is was planned and anticipated to be done before the post operative period on the original knee was over. The title is "Staged or Related"..and since this was discussed and planned for in the initial preoperative stage of the first knee, and it is the same procedure just opposite side, seems like it could meet that description.

Of course the argument that 79 is better if the procedure considered "unrelated" since it was the opposite knee also works. The coder will have to decide which better fits the situation.
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I'm getting hung up on the same thing - I think it's something that CPT should do a better job of clarifying. Allow me to think out loud here for a second - I'm not trying to debate this with anyone - I don't know the answer...
Really, a doctor could plan to do a different surgery on the same patient every day for a week, but the surgeries could be totally unrelated. If you think about it, except in the case of emergency surgeries, ALL surgeries are planned ahead of time - the only distinction here, is that the patient needed more than one thing operated on, and they decided to do the operations during different sessions.
As I mentioned before, it would have been possible to perform both surgeries in the same session - they were truly independent procedures, and would have both been payable on the same DOS, if that were a practical way to do that sort of thing. I guess what I'm unclear on, is - does it matter why the procedures were planned to be performed separately, or should the planning have some correlation to the provider's ability to perform the procedures (or the patient's ability to tolerate both procedures) in one or more sessions?

Just to be the devil's advocate for a second: here's a different example - let's say that a patient needs to have an I&D of a cyst done on her shoulder, and to have some sort of lesion excised from her leg, and figures this all out during a well check. She could get them both done at once, but the doctor's only got open appointments that week, and the appointment times available don't work well with the patient's busy schedule, so they decide to split the procedures up and do them on 2 different days. In a situation like that, would you consider those procedures staged, simply because they planned to do them on different days?

Now with this situation, the impracticality of doing both procedures has a more substantial basis - for the patient's recovery, and their ability to have some sort of mobility during recovery, it becomes necessary to do the procedures at different times. Does the patient's convenience during recovery constitute medical necessity for performing the procedures on different dates, or is the medical necessity of the procedures' timing determined based only on what's required to achieve both operations safely and successfully?

I think the answer to that riddle would shed some light on this issue - I'm interested in finding out the answer, though - I'll do some digging to see if I can come up with anything. Surely this isn't the first time someone's had this conundrum...:confused:

(btw...Remember that show "The Swan", where they took those ladies and gave them a complete plastic surgery makeover within a couple of months? Can you imagine trying to code that?!?)
 
Brandi - I do like the way you think! LOL! This is a topic that could be debated all day from any number of angles! Kind of fun sometimes to consider all the possibilities on some our coding issues. Would be cool to have a round table discussion on this type of topic at national conference! Just gets the blood pumping!
 
ajs said:
Brandi - I do like the way you think! LOL! This is a topic that could be debated all day from any number of angles! Kind of fun sometimes to consider all the possibilities on some our coding issues. Would be cool to have a round table discussion on this type of topic at national conference! Just gets the blood pumping!
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Haha! I thought the same thing about the round-table - I was considering sending it out to the coders in my company to pick their brains on it - it seems like such an impossible question! I also thought about calling someone from CMS and asking them, just to see if it would stump any of them, too...
 
I think I may have found the answer: check with your MAC...(That seems to be the answer a lot...)


Here's what Trailblazer says:
http://www.trailblazerhealth.com/Publications/Training Manual/Surgery.pdf

"Do not use this [modifier 58] for a truly unrelated procedure that is performed within the follow-up period of another surgery by the same surgeon. Modifier 79 would be the correct modifier for the second procedure.

Example 1:
Patient had a breast lesion removed (19120) followed in less than 90 days by the removal of the entire breast (19303). Provider should bill 19303 with modifier 58 for the second procedure.
Example 2:
A total knee replacement (27447) was performed and four weeks later a manipulation of the knee under anesthesia for adhesions (27570) was performed. In this scenario, the knee manipulation could be considered therapeutic but the total knee is also therapeutic, not diagnostic; therefore, modifier 58 should not be used.
Example 3:
A total knee replacement (27447) was performed and six weeks later an arthrocentesis (20610) was performed. Since the arthrocentesis is within the global period of a therapeutic procedure, the modifier 58 would not be appropriate.

Modifier 79
"This modifier should be used to show that a second procedure by the same physician (or physician of the same specialty in the same surgical group) is unrelated to the previous procedure that has not finished its postoperative period. Documentation, suchas a different ICD-9-CM diagnosis code, will usually be sufficient.
T
his modifier is often necessary with identical surgical procedures that are not done on the same day, such as in cataract surgery where both eyes are done within a 90-day period.
Note: Using the RT (right) and LT (left) modifiers is helpful, but should be used in addition to the 79 modifier, not in place of it."

There's also a 'when to use' chart for the modifiers - I'd say 79, if you use Trailblazer... ;)
 
I would use mod 79 not mod 58. One the opposite knee has NOTHING to do with the surgery from the first knee. You can use RT and LT to notify the insurance that the knees are different. I automatically send Op report with surgeries which will show the two separate knees. If there are complications from either surgery and the doc has to go back in for any reason, you will be glad you chose modifier 79. I know Ive had to bill for it.

I cannot see how modifier 58 would be appropriate. I use mod 58 for procedures that are really no more than a week apart, usually 3 days or so and require a part A and part B of the same procedure. And the second procedure is usually paid less than the first.

Barbara
 
I wa going to saythe RT and Lt also. I have billed many of these and have always used the RT and LT modifiers and never any problems. This is the reason these modifers are there. of course if you did not bill the first one with the anatomic modifier it is much more difficult. You will probably need to go back and submit a corrected claim for the first one.
 
-RT and -LT modifiers

Actually I would have used the -RT (or -LT) modifier on the first operation. Then I would have used the -79 / LT (or -RT) modifier on the second operation. The second knee operation is not related to or staged from the first operation because it is a different body part.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
Actually I would have used the -RT (or -LT) modifier on the first operation. Then I would have used the -79 / LT (or -RT) modifier on the second operation. The second knee operation is not related to or staged from the first operation because it is a different body part.

Hope that helps.

F Tessa Bartels, CPC, CEMC
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Sounds reasonable!
 
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