Thursday, May 5, 2011

Modifier 79 with example usage

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

The physician may need to indicate that the performance of a procedure or  service during the postoperative period was  unrelated to the original procedure. This circumstance must be reported by using the CPT modifier 79.

Instructions

This modifier is used when an unrelated procedure or service, by the same physician, is performed during the postoperative period (10 or 90 day global) of the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Correct Use

    Only on surgical codes
    Append modifier 79 in first position as pricing modifier
        Not necessarily needing return to operating room
        Failure to append could result in noncoverage
        For repeat procedures on same day, append modifier 76

Incorrect Use

    If Medicare Physician Fee Schedule (MPFS) indicator list marked with "XXX," no modifier is needed as there are no global dates

Claim Coding Example

    Provider performs right toe amputation on May 24, 2015.
    On June 25, 2015, a left foot amputation surgery was medically necessary within this 90 day global period

Date Treatment Description CPT/Modifier
5/24/15 Amputation big toe, RT 28820 TA
6/25/15 Amputation foot, LT 28800 79

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.

• Unrelated Procedure or Service by the Same  Physician During the Postoperative Period

• Performance of a procedure or service during the  postoperative period unrelated to the original  procedure

• Regardless of whether the subsequent surgery  required a return to the operating room

• Can only be used on surgical codes

• No additional documentation is required with the claim

• Supporting documentation must be maintained in the  patient’s medical records substantiating that the  surgeries were unrelated

• Allowance is based on the full fee for the procedure


Modifier 79 definition - Unrelated procedure by the same physician during the postoperative period


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.

Appropriate Usage

• To describe an unrelated procedure performed during the post-operative period of the original procedure.

• The two procedures are performed by the same physician or physician billing group.

• Pertains to all procedures codes with a 10-90 day global period.

• Modifier 79 should be appended to the second procedure.


Inappropriate Usage

• The procedure performed is related to the original procedure or a staged procedure.

• If the services performed are related to the original procedure, it is part of the global period.


Examples:

• The patient had a Diskectomy with fusion of the L4-L5 vertebrae 70-days ago. The patient tripped at home and fractured the right radial shaft. The surgeon who performed the Diskectomy is contacted and performs a closed manipulation of the radial shaft and applies a cast. The second procedure is unrelated to the first procedure. (CPT code 25505-79)

• Cataract surgery is performed on the left eye. During the global period, cataract surgery is performed on the right eye by the same physician. (CPT code 66984-79-LT).

• Patient has a repeat FEM-POP done on June 1st and is released from the hospital. A week after being home, patient is re-hospitalized on June 9th with renal failure. Hemodialysis is indicated and the same physician inserts a cannula for hemodialysis on June 10th the physician’s services for the insertion of the cannula for hemodialysis is unrelated to the FEM-POP performed during the previous hospitalization. (CPT code 36810-79).


Payment Guidelines

The longest global period for any procedure code from the original date of surgery applies to the entire surgical session and all subsequent services until the global period is complete. When using modifiers, choose the appropriate modifier for the situation, and use that modifier correctly.

The failure to use a needed modifier when appropriate may result in denial of the subsequent surgery. The incorrect use of a modifier when not appropriate may also result in denial of the subsequent surgery.

Modifiers 58, 78, and 79 are not valid to use with or attach to evaluation and management (E/M) procedure codes.

Modifiers 58, 78, and 79 are mutually exclusive to one another; only one of these modifiers may apply to a service or procedure performed within a postoperative global period.

Services may not be “unrelated” to the procedure code creating the postoperative global period and also “related” to another procedure code performed by the same physician during that same  original surgical session.

Multiple Procedures During the Same Surgical Session

Modifiers 78 and 79 should not be used to distinguish multiple procedure codes performed during the same operative session. The postoperative period does not begin until the surgical session ends. This is not a valid use of modifier 78 or 79, and represents a billing error.



For example:

During the initial surgery performed by this provider, a variety of procedures are performed on multiple skin lesions in multiple locations during the same surgical session. Neither modifier 78 nor modifier 79 should be attached to the procedure codes for the second and third lesions treated. Treatment of a second, separate lesion is correctly identified with the Distinct Procedural Service modifier (-59).

** Left eye cataract removal within the global period of right eye cataract removal is unrelated; submit with modifiers 79, XS, and LT.

** Right total knee replacement within the global period of left total knee replacement is unrelated; submit with modifiers 79, XS, and RT.

** 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa) performed on the operative joint during the global period is related. Do not report with modifier 79, 58, or any other modifier (*see general anesthesia exception below).

o If performed in the office or at the bedside, 20610 is not eligible to be separately reported or reimbursed during the postoperative global period. This service is included in the global surgery package for the original surgery.

o If general anesthesia is required with a return to the operating room, then 20610 is eligible for separate reimbursement for the intraoperative work; *submit with modifier 78.


During the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance must be reported by using the CPT modifier 79. For repeat procedures on the same day, see CPT modifier 76. 

URMC Compliance Office Guidance for use of Modifier 79 

Unrelated procedure/service by the same physician during the post-operative period Modifier 79 Unrelated procedure/service by the same physician during the post-operative period: use modifier 79 to report an unrelated procedure or service performed during a postoperative period that is unrelated and not a result of the first surgery. NOTE: This modifier should not be appended to an E&M service. (See modifier 24) (CPT, 2011) Appropriate Usage

• To describe an unrelated procedure performed during the post-operative period of the original procedure.

• The two procedures are performed by the same physician or physician billing group.

• Pertains to all procedures codes with a 10-90 day global period.

• Modifier 79 should be appended to the second procedure.

• The procedure performed is related to the original procedure or a staged procedure.

• If the services performed are related to the original procedure, it is part of the global period.


79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

• Modifier 79 indicates the performance of a procedure or service during a post-operative period was unrelated to the post-operative care of the original procedure.

 • Append modifier 79 to the procedure performed. 

• Documentation should support the procedure code reported. Documentation of a different ICD-9-CM code from the original procedure is usually sufficient to support that the procedure is unrelated to the original procedure.


• A new global period is initiated for the procedure reported with modifier 79.


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.


Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.

This circumstance may be reported by using the CPT modifier 79.

Note

** Carrier may deny if modifier 79 is not included on the submitted claim.

** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.

** The unrelated procedure starts a new global period.

** For repeat procedures on the same day, see modifier 76.

** Do not report modifier 79 with modifiers 58 or 78.

** Modifier 79 is an information modifier (not subject to payment reduction).

NCCI PTP-Associated Modifiers

The NCCI PTP-associated modifiers are the following:

Anatomical modifiers: RT, LT, E1 – E4, FA, F1 – F9, TA, T1 – T9, LC, LD, LM, RC, RI

Non-anatomical modifiers: 24, 25, 27, 57, 58, 59, 78, 79, 91, XE, XP, XS, XU

The state’s claims processing system must recognize all of these modifiers and allow the PTP edit to be bypassed, if any of these modifiers is appended to the appropriate code of the edit pair with a modifier indicator of “1” and if the other conditions specified in the Claim Adjudication Rules section below are met.

Failure to do this will result in incorrect denials of payment that will be incorrectly attributed to NCCI.

After code pairs that match NCCI PTP edits in the edit file with dates of service within the effective period of the corresponding edit and with a column one code that is eligible for payment are identified, determine whether an NCCI PTP-associated modifier is correctly appended to either or both of the codes of the code pair.
Proceed as follows:

(i) If the modifier indicator of the edit is “0”, the column two code is denied (not payable) regardless of whether an NCCI PTP-associated modifier is appended. These edits cannot be bypassed.

(ii) If the modifier indicator of the edit is “1” and if no NCCI PTP-associated modifier is correctly appended to either code, the column two code is  denied.

(iii) If the modifier indicator of the edit is “1” and if an NCCI PTP-associated modifier is correctly appended to an appropriate code in the edit, the PTP edit is bypassed and the column two code is eligible for payment. An exception to this rule is that if both codes have the same anatomical modifier (see above) and neither code has modifier 58, 59, 78, 79, XE, XP, XS, or XU, the PTP edit is NOT bypassed and the column two code

(iv) If the modifier indicator of the edit is “9”, both codes are eligible for payment. The corresponding edit is inactive and was deleted retroactive to its implementation dateis denied.


3 comments:

  1. My cousin recommended this blog and she was totally right keep up the fantastic work!



    Day Care Centres

    ReplyDelete
  2. A patient undergoes a Total abdominal colectomy with end-ileostomy. and than is undergoes a reversal of ileostomy with in the global period which modifier do I use 78 or 79??

    ReplyDelete
  3. A patient has a Total abdominal colectomy with end-ileostomy. And than undergoes a reversal of ileostomy within the 90 day global, which modifier should I use? 78 or 79.

    ReplyDelete

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