August 01, 2014
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.
By appending modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period to a CPT® code, you indicate three conditions:
- That the patient experienced a complication of surgery;
- Treatment of the complication required a return to the operating room (OR); and,
- The return to the OR occurred during the global period of the previous surgery.
The Centers for Medicare and Medicaid Services (CMS) defines an OR “as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It 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 there would be insufficient time for transportation to an OR).”
To support the return to the OR, you should cite the diagnosis that describes the complication, not the condition that prompted the initial surgery.
For example, on June 1 the patient undergoes a partial colectomy (90-day global period). On June 8, the patient is returned to the operating room for treatment of partial dehiscence of the incision with secondary suturing of the abdominal wall. Appropriate coding is:
- June 1: 44140, Colectomy, partial; with anastomosis with 153.3 Malignant neoplasm of colon; sigmoid colon.
- June 8: 49900-78 Suture, secondary, of abdominal wall for evisceration or dehiscence with 998.32 Other complications of procedures, NEC; disruption of wound; disruption of external operation (surgical) wound.
Modifier 78 does not reset global days from the previous surgery and, typically, you do not receive full reimbursement for the surgery to treat the complication. Many insurers reimburse only the intra-operative portion of the usual fee schedule payment (usually 70-90 percent of the total).
Do not confuse modifier 78 with similar modifiers 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period and 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
While modifier 78 applies when a return to the operating room is unplanned, modifier 58 applies when a procedure is:
- Planned prospectively or at the time of the original procedure;
- More extensive than the original procedure; or,
- For therapy following a diagnostic surgical procedure.
Like modifier 78, modifier 79 describes a return to the OR during the global period of another procedure, but modifier 79 indicates the subsequent procedure is unrelated to the initial surgery (i.e., is not prompted by a complication or result of the initial surgery). When you append modifier 79 to a claim, a new global period begins and the subsequent procedure is paid at 100 percent of the allowed amount, as determined by the carrier.
For example, on July 1 a patient undergoes surgical treatment of a closed fracture of the right ulna. The next day, the same patient comes to the emergency room with an uncontrolled nosebleed. The same physician returns the patient to the OR to repair a posterior arterial hemorrhage with cautery. Appropriate coding is:
- July 1: 25535-RT Closed treatment of ulnar shaft fracture; with manipulation with 813.22 Fracture of radius and ulna; shaft, closed; ulna (alone).
- July 2: 30905-79, Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial with 784.7 Epistaxis.