The Coding Sleuth 20
by Tara Conklin
The Case of the Maddening Modifiers – Last Episode…Promise
This is our last trip in the rather frightening neighborhood of modifiers. So far we have taken the bark out of E&M modifiers, Pre-surgical and post-surgical modifiers. We have so far survived with only bumps and bruises. Our last trek is going to take us face to face with modifiers used for procedures in the post-operative period.
All too often patients end up back in the operating room during the post-operative period of another period. Sometimes the reason may be related to the previous procedure; other times it’s for something all together different. What’s important is painting the perfect picture of what happened on the claim.
-76 Our first modifier is used to report a repeat procedure by the same physician. This may seem pretty straight forward but it has a few little nuances. Most of the time this modifier only comes in handy when the same procedure, reported by the same CPT code, is repeated on the same day. This is commonly used when x-rays are done again the same day after fracture casting, to check for alignment. Another use many be when more than one EKG is performed or injections. Any number of reasons could apply. The key is remembering these key components; the same day (usually), the same CPT code, most of the time the same site or reason.
-77 Looks a lot like its maternal twin -76. To be honest, it look and acts and walks just like -76. The only thing that changes is the physician performing the procedure.
-78 & -79. We’ll look at both of these together since they bring us into territory that can often leave any coder lost in confusion. Return to the operating room for a related or unrelated procedure during the post-operative period is all about determining just exactly what is considered “related.” Perhaps the best way to explain this is to understand it’s not always about the medical condition that prompted the return procedure. Granted the medical condition can be an important factor but the first thing a coder should ask themselves is “is the medical condition being treated directly related to the initial medical condition and at the same or different site from the first procedure.” For example, did an abdominal abscess initially incised and drained require additional draining during the postoperative procedure? Perhaps the abscess was found to be larger than initially thought and a new incision is made to gain access to the rest of the abscess. Even though a new surgical site was created, the condition prompting the procedure is the same condition treated originally.
Another example of a “related procedure” is when a complication arises which requires a new procedure, such as an infected incision site. If a graft inserted initially becomes thrombosed, or infected and a new graft is inserted during the postoperative period, this also would be a related procedure even if the new graft was at a completely different site.
An unrelated procedure would of course be the complete opposite of the example listed above. However, anything else done for a separate condition would also be unrelated. A colostomy during the postoperative period of a lung lobectomy would be unrelated…for obvious reasons. Let’s look at our vascular bypass graft. If during the postoperative period the patient develops an occlusion at a different site or perhaps the occlusion was already pre-existing and another graft is inserted, this would be unrelated to the original procedure because it’s independent of the original graft and condition.
Now that you understand related vs. nonrelated, we’re not quite done yet. The last modifier we need to examine is modifier 58. This appears to be similar to 78 because they are both used to report a “related” procedure during the post-operative period. 58 is used primarily to report staged procedures (a procedure that was scheduled to be done or known it would need to be done, prior to the first trip to the operating room). This second surgery may be completely different and independent of the first procedure. Multiple procedures may be scheduled at the same time but for certain reasons, they all need to be carried out at different times. All scheduled procedures, subsequent to the initial surgery would be billed with modifier 58 whether they are related or not. The trick to this one is it’s not used to report a complication arising during the postoperative period. This would fall back on 78 and 79. An example may arise when a patient is scheduled to have several diskectomies done. However, to promote healing or to reduce the discomfort to the patient, they are all scheduled on separate days. Let’s say a disc from the cervical spine, one from the thoracic and one from the lumbar are all scheduled for surgery. Their conditions are all independent but they are done on different days. Perhaps a patient suffered three bulging lumbar discs from a traumatic fall. The conditions are related but they are operated on separately on different days. These are all examples in which modifier 58 would be used and not 78 or 79.
I hope this helps to clear up some of the confusion with some of the most commonly used modifiers. Together they make a formidable gang, but get them all separate of one another and they crumble like cake. If you have any other questions, please feel free to contact me The Coding Sleuth at tlconklin@gmail.com
Until next time coders...
--Tara