78: The “Complications” Modifier

78: The “Complications” Modifier

Be sure it’s a new condition and related to the original surgery, not the underlying condition.

By G.J. Verhovshek, MA, CPC

If the same provider returns a patient to the operating room (OR) during the global period of a previous procedure to treat a complication of that earlier surgery, append modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period to the CPT® code describing the follow-up procedure.

Note: Under the Centers for Medicare & Medicaid Services’ (CMS) guidelines, the “same physician or other qualified healthcare professional” includes providers within the same physician group.

The term “related procedure” in the modifier 78 descriptor means the follow-up procedure is related to the original surgery, not to the underlying condition that prompted the original surgery. That is, the diagnosis linked to the follow-up procedure will describe a new condition (i.e., a complication of surgery) that will differ from the diagnosis linked to the initial surgery.

For example, a patient suffers from diabetes and severe peripheral vascular disease, which results in gangrene of the right lower extremity. August 19, the patient’s foot is amputated at midtarsal region, with the hope of saving the remainder of the limb. Three days later, the patient is brought back to the OR for postoperative infection with debridement of the bone measuring 16 sq cm. The appropriate coding is:

August 19:

28800-RT Amputation, foot; midtarsal (eg, Chopart type procedure)-Right side

250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled

785.4 Gangrene

August 22:

11044-78-RT Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

998.59 Other postoperative infection

Notice the use of different diagnoses for the original and follow-up procedures.

Return to the OR Is Crucial

CMS defines an OR “as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).”

To append modifier 78 appropriately, the patient must be returned to the OR. This is especially important for Medicare beneficiaries. If the provider is able to treat the complication without a return to the OR, Medicare will bundle the treatment into the initial procedure’s global surgical package. The Medicare Claims Processing Manual, chapter 12, specifies, “… the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room.”

By contrast, the General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, chapter 1, stresses, “Control of postoperative hemorrhage is … not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.”

78 Leads to Decreased Payment

Modifier 78 does not reset global days from the previous surgery; and, typically, you do not receive full reimbursement for the surgery to treat the complication. Many insurers reimburse only the intra-operative portion of the usual fee schedule payment (approximately 80 percent of the total).

Differentiate 78 from 58, 79

Don’t mix up modifiers 78 and 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period. Both modifiers describe a return to the OR during the global period of another procedure, but modifier 79 indicates the subsequent procedure is unrelated to the initial surgery. In other words, the follow-up procedure is not a result of the initial surgery or the diagnosis that prompted it. When you append modifier 79 to a claim, a new global period begins and the subsequent procedure is paid at 100 percent of the allowed amount, as determined by the carrier.

For example, a patient undergoes a total abdominal hysterectomy on April 10. At a post-operative checkup, the physician discovers a Bartholin’s gland cyst, which she removes.

April 10:

58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)

Follow-up:

56440-79 Marsupialization of Bartholin’s gland cyst

In some cases, modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period, rather than modifier 78, may properly describe a return to the OR during the global period. CMS policy (Medicare Claims Processing Manual, chapter 12, section 40.1.B) states, “If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.” In such a case, modifier 58 is appropriate.

For more information on modifier 58, see “58: The ‘Goes Beyond’ Modifier” in the June 2015 issue of Healthcare Business Monthly.


 

G.J. Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Asheville-Hendersonville, North Carolina, local chapter.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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