Wiki Modifier 76 & global period

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PMiklavcic

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Our doctor saw a patient for an I&D (10 day global period) of a finger abscess & has been seeing the pt for f/u which falls in the global period.......8 days later the doctor had to re-I&D the abscess......is the 76 modifier appropriate for the 2nd I&D? & does the global period start over with the 2nd I&D? (the doctor is seeing the pt on day 12 for f/u & I'm not sure if this is global or billable) Any help is appreciated.

Thank you!
 
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no, 76 wouldnt be correct, that's only if the procedure was repeated on the same day. for this I would guess 78, because the doctor didnt plan on doing another I&D right? if it was planned or staged then 58 would be appropriate, otherwise use 78 for an unplanned return to OR for a related procedure. for modifier 58 the global the global resets, but for 78 it does not. this is because 78 is usually used when you have to go back and fix something. as far as day 12 follow up, if it's unplanned like I think it is then you should be ok, because the global will not have started over again. does this all make sense?
 
This is being done in an office setting (PCP office)......I was going back & forth b/t the 76 & 78 & was thinking the 78 was more appropriate but the "return to the OR" was throwing me off being that it was being done in the office.

The re-I&D was not planned at all......so if I am understanding correctly, the global period does not start over w/the 2nd I&D so the f/u on day 12 of the original I&D is billable to the insurance co, correct??

I appreciate your time & response.
 
Yeah, you would still use 78, because the guidelines state that it doesnt necessarily have to be an OR, or the same OR. It's more to represent the fact that you had to perform another related procedure during the global period, and that it was not planned (usually due to a complication, but sometimes not). And yes because global does not reset with 78 you should have the green light to bill the f/u on day 12, and unless there is anything else involved you wont need a modifier.
 
The information previously provided for Modifier 76 is inaccurate. Modifier 76 is not used just for same day only. Please see below :) , plus some added on info regarding the other modifiers useable within the surgical post operative period.


Modifier -76: Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service OR within the post-operative period. [Used for Outpatient and in office procedures] [Global does not reset]

So yes, you can used Modifier 76 when the same exact procedure and same diagnosis code is being repeated during the global period, if there is no extra/extensive work or new diagnosis.

-Example 1: Patient had an Incision and Drainage 26011 for cellulitis of the finger, within the 10 day global they need to go back in for repeat of the same procedure code and same cellulitis diagnosis (this is the same example from the initial question of this thread).
-Example 2: Patient had Dupuytren's Contracture and went in for procedure to excise the palmar fascia 26121, but within the 90 day global they are having to go back again for the same procedure, which is not uncommon for this to happen with Dupuytren's Contracture.

Modifier 58 would be used when it was planned prior to the original surgery taking place or a more extensive procedure [Modifier used for outpatient and in office procedures] [Global starts over, unless the new procedure has a 0 or 10 day global expiring before initial active 90 day global ends].

-Example (unplanned): Patient had closed reduction pinning of a fracture, during post operative appointments for return of x-rays to see how the healing is progressing there could be a possible healing delay or a malunion/nonunion and the patient needs to go back to surgery to remove the pins and convert over to an open approach with plate/screws, excision of bone defect and/or bone grafting.
-Example (planned): Patient had closed reduction pinning of a fracture with use of Kwires and has healed as expected, they come in for post operative appointment in office to have the Kwire pins removed, 20670.

Modifier 78 would be used if it is an unplanned procedure because a complication occurred resulting with a possible change in diagnosis related to the primary diagnosis from the original procedure [Modifier accepted for Outpatient only, not useable for in office procedures] [Global does not start over].

-Example: Patient had an open repair of a fracture, they are now coming back in for pain at the site of where the hardware was placed. XRAY imaging is showing there is mechanical complication from internal hardware placed and the patient needs to go back to surgery to have the hardware removed, and also the need to replace the hardware would also be coded with modifier 78. Removal of internal plates and screws is most always considered unplanned as they normally do not come out and insurance does not pay for staged internal hardware removal unless there is medical necessity to prevent further complications.

Modifier 79 would be used if it is a new diagnosis being billed out as a sequela to the primary diagnosis or unrelated body part/system than what the patient was originally being treated for [Modifier accepted for both outpatient and in office procedures] [New global period starts].

-Example 1: Patient had an Open Repair of a fracture, Patient comes back in and now has an infection of the bone and new diagnosis is acute Osteomyelitis sequela to the fracture. Patient is now going back to surgery to have their distal phalanx resected due to a bone infection. Doctor is now treating an infection and no longer the fracture.
-Example 2: Patient had open repair of the fracture but during the post operative period the incisional site is not healing and has opened back up, patient needs wound repair of the surgical incisional site which ends up being done in the office, the doctor is now treating the incisional wound and no longer the fracture. HOWEVER, check your insurance guidelines Medicare does not like to approve 79 for post op infections and usually have to bill out modifier 78 which is only allowed in outpatient settings.
 
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AM4255 said:
The information previously provided for Modifier 76 is inaccurate. Modifier 76 is not used just for same day only. Please see below :) , plus some added on info regarding the other modifiers useable within the surgical post operative period.


Modifier -76: Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service OR within the post-operative period. [Used for Outpatient and in office procedures] [Global does not reset]

So yes, you can used Modifier 76 when the same exact procedure and same diagnosis code is being repeated during the global period, if there is no extra/extensive work or new diagnosis.

-Example 1: Patient had an Incision and Drainage 26011 for cellulitis of the finger, within the 10 day global they need to go back in for repeat of the same procedure code and same cellulitis diagnosis (this is the same example from the initial question of this thread).
-Example 2: Patient had Dupuytren's Contracture and went in for procedure to excise the palmar fascia 26121, but within the 90 day global they are having to go back again for the same procedure, which is not uncommon for this to happen with Dupuytren's Contracture.

Modifier 58 would be used when it was planned prior to the original surgery taking place or a more extensive procedure [Modifier used for outpatient and in office procedures] [Global starts over, unless the new procedure has a 0 or 10 day global expiring before initial active 90 day global ends].

-Example (unplanned): Patient had closed reduction pinning of a fracture, during post operative appointments for return of x-rays to see how the healing is progressing there could be a possible healing delay or a malunion/nonunion and the patient needs to go back to surgery to remove the pins and convert over to an open approach with plate/screws, excision of bone defect and/or bone grafting.
-Example (planned): Patient had closed reduction pinning of a fracture with use of Kwires and has healed as expected, they come in for post operative appointment in office to have the Kwire pins removed, 20670.

Modifier 78 would be used if it is an unplanned procedure because a complication occurred resulting with a possible change in diagnosis related to the primary diagnosis from the original procedure [Modifier accepted for Outpatient only, not useable for in office procedures] [Global does not start over].

-Example: Patient had an open repair of a fracture, they are now coming back in for pain at the site of where the hardware was placed. XRAY imaging is showing there is mechanical complication from internal hardware placed and the patient needs to go back to surgery to have the hardware removed, and also the need to replace the hardware would also be coded with modifier 78. Removal of internal plates and screws is most always considered unplanned as they normally do not come out and insurance does not pay for staged internal hardware removal unless there is medical necessity to prevent further complications.

Modifier 79 would be used if it is a new diagnosis being billed out as a sequela to the primary diagnosis or unrelated body part/system than what the patient was originally being treated for [Modifier accepted for both outpatient and in office procedures] [New global period starts].

-Example 1: Patient had an Open Repair of a fracture, Patient comes back in and now has an infection of the bone and new diagnosis is acute Osteomyelitis sequela to the fracture. Patient is now going back to surgery to have their distal phalanx resected due to a bone infection. Doctor is now treating an infection and no longer the fracture.
-Example 2: Patient had open repair of the fracture but during the post operative period the incisional site is not healing and has opened back up, patient needs wound repair of the surgical incisional site which ends up being done in the office, the doctor is now treating the incisional wound and no longer the fracture. HOWEVER, check your insurance guidelines Medicare does not like to approve 79 for post op infections and usually have to bill out modifier 78 which is only allowed in outpatient settings.
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You might further research this- everything I can find specifies that modifier 76 is for repeat of a procedure on the same day only.

 
iowagirl77 said:
You might further research this- everything I can find specifies that modifier 76 is for repeat of a procedure on the same day only.

Click to expand...
I unfortunately still need to standby my information provided on Modifier 76 and do not agree the use of 76 modifier is for same day only. If you read the definition of the modifier itself on the nationally recognized sites and published coding books, it does not restrict the code in definition to same day only.

Novitas, CMS, and AAPC from the providing articles above are giving their say on how to bill out for the same day only scenario as it is the most often use, they are not providing definition to the modifier code itself. The listed out articles state "on same day" because it is strictly educating only the use of modifier 76 correctly used on same day claims to keep from a denial with duplicate procedures on the same day . These articles are creating strict minded use of the modifier for us coders and a second guess for the additional scenario of same billed CPT code on another date.


AMA guidelines reported in Coding With Modifiers: A Guide to Correct CPT and HCPCS Level II Modifier Usage:
  • Modifier 76 should be used to for all procedures when the physician repeats the procedure the same day or during the postoperative period.
  • The procedure repeated must be the same procedure (same procedure code) by the same physician.

When navigating through the CPT coding book under appendix A, description for Modifier 78 has as the last statement "(For repeat procedures, see modifier 76)"

Modifier 78 is being argued as the appropriate modifier on repeated procedures not on the same day due to its use being an unplanned related procedure to the first surgery. Related procedures mean they are for a different type of method from the first procedure, or more extensive procedures to be performed that weren't enough to succeed with the first operation. And not all the time are these procedures the SAME CPT code being billed out previously, so it is more common for us to not think about the use of modifier 76 when a patient is within their post operative global period. BUT when it is the SAME CPT code an identical match being repeated within their post operative global period you use Modifier 76, if they are entirely new CPT codes being billed out you use modifier 78.

Related: associated with the specified item or process (a new or additional procedure being performed for the same diagnosis already treated, different CPT codes not previously billed out)
Repeated: an action, event, or other thing that occurs or is done again (procedure done exactly the same way, same identical CPT codes previously billed out)


You can check the use of the modifier with most insurance billing guidelines, they also are in agreement with my argument of the Modifier 76 as they are required by law to process medical claims off published guidelines.

Example 1: BCBS Horizon Reimbursement Policies & Guidelines
"Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service or within the post-operative period."

Example 2: BCBS Premera Payment Policy
"The Plan recognizes Modifier 76 when appended to a service/procedure to indicate that the same service/procedure was repeated by the same physician or other qualified healthcare professional for the same patient, often on the same day but at a separate and distinct subsequent session, usually during the global period of the original procedure."


However, you will come across Medicare and Medicaid payors that do not allow the use of Modifier 76, and you will then have to submit medical necessity to get it paid. You truly are not to over ride that rule and rebill the claim out with a 78 for audit reasons. Repeated procedures, same identical codes being billed, are not covered under the plan for treatment, a repeat is not allowed and would be the patients responsibility. If you are incorrectly sending out a repeat procedures with a 78 modifier to override the non allowed modifier in their system and they pay for the surgery, that in a way is a fraudulent claim to get paid. From the payors argument they do not approve for the same exact procedure to be done again, if it didn't work the first time why would they pay for a second time, if the patient is going back to be operated on again it needs to be a different type of procedure or something more extensive than the first. Therefore using modifier 76 is the correct use on different date same procedures for accurate clean claims being sent to insurance companies.
 
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