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


Return Trips to the Operating Room During the Postoperative Period

When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, use  the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for theoriginal surgery is not used except when the identical procedure is repeated.  In addition to the CPT code, physicians use CPT modifier “-78” for these return trips (return to the operating room for a related procedure during a postoperative period.)

The physician may also need to indicate that another procedure was performed during the postoperative  period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for this modifier does not limit its use to treatment for complications.

Unrelated Procedures or Visits During the Postoperative Period

Two CPT modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure.

Modifier “-79: Reports an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.

A new postoperative period begins when the unrelated procedure is billed.

Modifier “-24: Reports an unrelated evaluation and management service by same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding the modifier “-24” to the appropriate level of evaluation and management service.

Services submitted with the “-24” modifier must be sufficiently  documented to establish that the visit was unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation.

A physician who is responsible for postoperative care and has reported and been paid using modifier “- 55” also uses modifier “-24” to report any unrelated visits.

Prepayment Edits to Detect Separate Billing of Services Included in the Global Package

In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy; and -

• Services that were furnished within the prescribed global period of the surgical procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.” A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254,
99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from  the excluded category and are now included in the global surgery edits.


Modifier “-78” Return to the Operating Room for Related Procedure During the Post-Operative Period

The “-78” modifier is typically associated with a complication that resulted from a previous procedure. By definition, there must be evidence of a return to the operating room. That reanytime in a 10- or 90-day global period (although if the same procedure is repeated on the same day, because of a complication, use a “-76” [repeat procedure modifier]). Medicare describes an “operating room” to include a typical operating room and endoscopy suite. It would not include an office treatment room, minor treatment room, patient’s room, ICU, or recovery room. Non-Medicare payers may be more lenient in  their operating room requirements (check with individual payers regarding their definition of “operating room” as it relates to the “-78” modifier). In all cases,  there needs to be clear evidence of medical necessity for the return to the operating room.

The “-78” modifier can be appended to an unlisted procedure code if no existing CPT surgical code exists. The global period does not  “begin anew” with the “-78” modifieruse. In most cases, payers only allow reimbursement for the surgeon’s intra-operative work (approximately 50% of the total fee schedule allowance).

Also, if, for example, a patient had a bunionectomy with osteotomy performed, and several days later tripped and displaced the capital portion of the metatarsal, the return to the operating room to remove the  fixation, realign the metatarsal head,and fixate it with a larger surgical screw (achieving a “solid” osteotomy site fixation), would not be CPT 28296-78; it would be either an open treatment of metatarsal fracture or an unlisted procedure. In other words,  you do not repeat the original procedure code unless you actually performed another bunionectomy with osteotomy.

Examples of a “-78” Modifier Use A return to the operating room to:

• Evacuate a large hematoma post-multiple midtarsal joint arthrodesis;

• Repair an extensive wound dehiscence of a surgical site (especially if the original surgery took significantly longer than expected to perform or the tissue was roughly handled);

• Perform an incision and drainage of a deep wound abscess that followed repair of laceration of tendons and other soft tissue (mower injury);

• Removal and replacement of internal fixation due to failure of the hardware to stabilize bone.

If a complication and return to the operating room for treatment can be attributed to something directly or indirectly associated in the performance of the original surgery, a “-78”  modifier would be applied. Post-operative infection is a complication. Pain from a poorly placed protruding surgical screw is a complication.

If a more extensive procedure is needed to be performed, not because of any performance issues, but failure of the original procedure to achieve its desired result, a “-58” modifier would be applied.

Examples of a “-78” Modifier Use A return to the operating room to:

• Evacuate a large hematoma post-multiple midtarsal joint arthrodesis;

• Repair an extensive wound dehiscence of a surgical site (especially if the original surgery took significantly longer than expected to perform or the tissue was roughly handled);

• Perform an incision and drainage of a deep wound abscess that followed repair of laceration of tendons and other soft tissue (mower injury);

• Removal and replacement of internal fixation due to failure of the hardware to stabilize bone. Modifier “-58” Staged or Related Procedure or Service by the Same Physician During the Post-Operative Period

The “-58” modifier differs considerably from the “-78” (return to the operating room for a related surgery complication in a post-operative period). While they have “related procedure” and “post-operative period.

Some Final Points and Reminders

• Unlike the “-78” modifier, the original procedure global period gets reset (“begins anew”) with the “-58” modifier use. In most cases, payers allow 100% of the total fee schedule allowance.

• It is critical, if you are going to use the “-58” modifier under its “staged” option, to document prior to performance of the procedure, the need for staging additional procedures or the possibility that additional procedures will need to be performed to achieve the ultimate surgical goal.

• The “-58” modifier is not used when there is a complication of the original surgery requiring a return to the operating room.

• Modifier “-58” procedures are not required, but may be performed in an operating room.

Modifier “-78” Return to the Operating Room for Related Procedure During the Post-Operative Period

The “-78” modifier is typically associated with a complication that resulted from a previous procedure. By definition, there must be evidence of a return to the operating room. That re turn to the operating room can occur anytime in a 10- or 90-day global period (although if the same procedure is repeated on the same day, because of a complication, use a “-76” [repeat procedure modifier]). Medicare describes an “operating room” to include a typical operating room and endoscopy suite. It would not include an office treatment room, minor treatment room, patient’s room, ICU, or recovery room. Non-Medicare payers may be more lenient in their operating room requirements (check with individual payers regarding their definition of “operating room” as it relates to the “-78” modifier). In all cases, there needs to be clear evidence of medical necessity for the return to the operating room.

The “-78” modifier can be appended to an unlisted procedure code if no existing CPT surgical code exists. The global period does not “begin anew” with the “-78” modifier use. In most cases, payers only allow reimbursement for the surgeon’s intra-operative work (approximately 50% of the total fee schedule allowance). Also, if, for example, a patient had a bunionectomy with osteotomy performed, and several days later tripped and displaced the capital  portion of the metatarsal, the returnto the operating room to remove the fixation, realign the metatarsal head, and fixate it with a larger surgical screw (achieving a “solid” osteotomy site fixation), would not be CPT 28296-78; it would be either an open treatment of metatarsal fracture or an unlisted procedure. In other words, you do not repeat the original procedure code unless you actually performed another bunionectomy with osteotomy.

Examples of a “-78” Modifier Use

A return to the operating room to:

• Evacuate a large hematoma post-multiple midtarsal joint arthrodesis;

• Repair an extensive wound dehiscence of a surgical site (especially if the original surgery took significantly longer than expected to perform or the tissue was roughly handled);

• Perform an incision and drainage of a deep wound abscess that followed repair of laceration of tendons and other soft tissue (mower injury);

• Removal and replacement of internal fixation due to failure of the hardware to stabilize bone

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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