Friday, June 3, 2011

Rules for Modifier 78 with example

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

It may be necessary to indicate that another procedure was performed during the  postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of the operating/procedure room, it may be reported by adding the modifier 78 to the related procedure.

Instructions

This modifier is appended to another surgical code for an unplanned return trip to the operating room during global post op (10 or 90 days).

Correct Use

    Append 78 modifier in first position as the pricing modifier
        E.g., Possible complications
    Payment limited to allotted intra-op services only
    Append modifier 58 if return procedure was staged or planned

Incorrect Use

    If Medicare Physician Fee Schedule (MPFS) indicator list marked with "XXX", then no modifier needed as the code has no global dates

Claim Coding Example

    Provider performs bypass on February 24, 2015, and then nine days later, because of a possible infectin, an unplanned return trip back to the operating room for a chest wall exploration.

Date

Treatment Description

CPT/Modifier

2/24/15

Coronary artery bypass

33514

3/5/15

Explore chest wall

35820 78


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.

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).


Fee Adjustments for Services within a Global Period

An unplanned return to the operating/procedure room for a related procedure during a postoperative global period (modifier 78) will be eligible for reimbursement at 70% of the allowance for that procedure.

Modifiers 58 (staged, related) and 79 (unrelated) are not subject to any global period allowance reductions. Documentation may be required for review to verify the services were staged or unrelated to the original surgical session.

Modifiers 58, 78, and 79 do not bypass the usual multiple procedure fee reductions, bilateral feeadjustments, assistant surgeon fee adjustments, or any other applicable adjustments which may apply to a particular line item or situation.


Hospital ASC and Outpatient Coders

Medicare’s instructions for modifiers 78 and 79 in hospital ASC or hospital outpatient facilities include in the definition procedures requiring a “return to the operating room on the same day.” Use modifier 78 for a procedure related to the initial procedure on the same day and modifier 79 for a procedure on the same day that is unrelated to the initial procedure

1 comment:

  1. If the procedure is done in an outpatient hospital clinic, can we still use mod 78? Or does it actually have to be in the main hospital OR?

    ReplyDelete

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