Wednesday, April 20, 2011

Incorrect usage of Modifier 24, 58, 78 and 79

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).

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