Cardiology Coding Alert

Question: A patient returned to the operating room to treat a complication within the global of an iliac aneurysm repair. How do I decide whether to use modifier 78 or 79? Is a complication "related"?

Maine Subscriber

Answer: For a return to the operating room to treat a complication, choose 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). As the descriptor states, using the modifier is appropriate only if the procedure requires a return to the OR or a procedure room, which may be a cath lab.

79 for new: Using modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) would be appropriate when you meet these conditions:

• The procedure or service is for a condition unrelated to the initial surgery
• The subsequent surgery occurs during the initial surgery's global period.