Modifiers in Postoperative Periods

December 29th, 2015 - Allison Singer, CPC
Categories:   Coding   Evaluation & Management (E/M)   Medicare Physician Fee Schedule (MPFSDB)   Modifiers   Surgical Billing & Coding  
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Modifiers in Postoperative Periods


Introduction

Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of those variables. A global period is the amount of time before, during, and after a surgical procedure that covers the typical patient care for that particular procedure. When a provider performs a new procedure or service on a patient who is within the global period of a previous procedure, the new procedure must be distinguished by using a modifier.


Modifiers 24, 58, 78, and 79 were created specifically to handle the various postoperative scenarios that often occur. When it comes to claims processing, these modifiers are well-known trouble spots that frequently generate reviews or denials. Practices that accurately apply modifiers 24, 58, 78, and 79 will see a decrease in claims denials and an increase in reimbursement.

Global Surgical Package

Any surgical procedure listed in the CPT® Manual (10021-69990) is subject to global periods under the Medicare Physician Fee Schedule. In the Medicare Physician Fee Schedule Database (MPFSDB), each procedure is assigned a global period status: 000, 010, 090, MMM, XXX, YYY, or ZZZ. The three global period statuses coders must pay attention to are 000, 010, and 090 for minor and major surgical procedures.

Note: To access the MPFSDB, go to: http://www.cms.hhs.gov/PhysicianFeeSched/01_overview.asp

Minor surgical procedures include either a zero or 10-day postoperative period, starting the day of the surgical procedure. Major surgical procedures include a 90-day postoperative period, starting either the day before or the day of the surgical procedure. When patient care falls within either the 10-day or 90-day global period, new services must be documented with a postoperative modifier.


When Not to Use Modifiers 24, 58, 78, and 79

Providers are not separately reimbursed for providing routine postoperative care during the postoperative period, even if the procedure is reported with a postoperative modifier. Routine postoperative care includes the following services:

  •  Treatment for complications following a procedure that does not involve a return trip to the operating room
  • Critical care services for seriously injured or burned patients
  • Follow-up E/M visits related to the patient’s recovery following surgery
  •  Pain management related to the surgical procedure
  • Dressing changes
  •  Local incisional care
  •  Removal of sutures, staples, lines, wires, tubes, drains, catheters, casts and splints

Basics Rules

Modifiers 24, 58, 78, and 79 have the following usage rules in common:

  1. The patient is already in a postoperative period for a previous surgery when the new procedure is performed.
  2. The new procedure is performed by the same physician that performed the previous surgery.
  3. Modifiers apply to the new procedure being performed that day.

Note: Payers consider physicians that belong to the same specialty and who are of the same group practice (identified by the same tax identification number) to be the “same physician.” 

Modifiers are also classified as either payment modifiers or information modifiers. Payment modifiers directly affect the reimbursement rate of a procedure or service’s allowable fee schedule. Information modifiers reference essential documentation details, such as, anatomic site. It may be necessary to apply more than one modifier to a surgical procedure in order to document the services accurately. To ensure proper payment, payment modifiers must be sequenced in the first modifier position before any information modifiers.

Note: Modifiers 58, 78, and 79 are combined frequently with laterality modifiers (RT, LT, and 50), anatomy-specific modifiers (E1, E2, E3, and E4), and assistant surgeon modifiers (80, 81, 82, and AS).


Modifier 24 - Unrelated evaluation and management by the same physician during a postoperative period

The following rules apply:

  • Modifier 24 is applied to only two possible code sets: evaluation and management (E/M) services (99201-99499) or general ophthalmological services (92002-92014), which are eye examination codes.
  • Modifier 24 is not valid with surgical procedures, labs, x-rays, or supply codes.
  • The new E/M service or eye exam usually involves a different diagnosis, but not always. For example, the same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.
  • Modifier 24 is not used to report exams performed for routine postoperative care.
  • Modifier 24 is an information modifier.

Example

Dr. Smith sees an established patient in his office who had a bike accident. Dr. Smith performs an intermediate repair for a 4.0cm wound on the patient’s forehead. The repair has a 10-day global period. Three days later, the patient sees Dr. Smith complaining about sinus trouble. Dr. Smith performs a problem focused exam and diagnoses the patient with a sinus infection. He writes a prescription and codes the visit as a 99212-24.

Modifier 58 – Staged/related procedure by the same physician during a postoperative period

The following rules apply:

  • Apply modifier 58 to surgical procedures that were (a) planned or anticipated at the time of the original surgery, (b) more extensive than the original procedure, or (c) for therapy following the original procedure.
  • The new surgical procedure usually involves a new CPT® or HCPCS code.
  • Do not apply modifier 58 to procedures whose definitions include the description “one or more sessions” (such as, 67105) if the subsequent sessions are performed during the postoperative period of the initial session. Modifier 58 may only be used with these types of procedure if a subsequent session is performed outside of the postoperative period of the original procedure.
  • The planned surgical procedure starts a new global period.
  • Do not report modifier 58 with modifiers 78 or 79.
  • Modifier 58 is an information modifier

Example

On February 1, a patient undergoes an iridotomy (66761) on his left eye. In the medical record, the surgeon states the patient may need a laser trabeculoplasty on the same eye. On April 10, the patient sees the doctor for a follow-up visit, and the surgeon decides to perform the second surgery the next day. The trabeculoplasty is billed as 65855-58-LT.

Modifier 78 – Unplanned return to the operating room by the same physician following the initial procedure for a related procedure during the postoperative period

The following rules apply:

  • Apply modifier 78 to unplanned or unanticipated surgical procedures that are performed to treat postoperative complications from the original surgery. Some examples of postoperative complications include excessive bleeding or infection.
  • The unplanned surgery always involves a separate operative session than the original surgery.
  • The unplanned surgery does not restart or begin a new global period.
  • Modifier 78 is not used to  report a repeat of the same procedure during the same operative session.
  • If modifier 78 isreported with assistant surgeon modifiers (80, 81, 82, and AS), list the assistant surgeon modifier first.
  • Do not report with modfiers 58 or 79.
  • Modifier 78 is a payment modifier. Procedures are reimbursed for the  intraoperative portion of the procedure (70 or 80 percent of the physician fee schedule for the surgical procedure).

Example

On April 1, a patient undergoes knee replacement arthoplasty (27440) on her right knee. The patient ends up with a severe knee joint infection. On April 30, the surgeon performs a knee arthrotomy (27310). Since the knee arthrotomy was performed less than 90 days after the original procedure, the procedure is reported as 27310-78-RT.

Modifier 79 – Unrelated procedure by the same physician during the postoperative period

The following rules apply:

  •  Modifier 79 applies to surgical procedures performed on patients while they are in a postoperative period for a different, unrelated surgery. The new surgical procedure is performed to treat a new problem or injury.
  • Modifier 79 is required when reporting identical procedures that are performed on the same day, but are not repeats of the same procedure on the same anatomical site.
  • The unrelated procedure starts a new global period.
  • Do not report with modifiers 58 or 78.
  • Modifier 79 is an information modifier.

Example

On May 1, a patient undergoes a complex cataract surgery (66982) on her right eye, and then has the same surgery performed on her left eye on June 1. The second cataract surgery on her left eye would be reported as 66982-79-LT.


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