Gastroenterology Coding Alert

Use these two case studies to test your understanding.

Although every GI physician strives to perform the fewest invasive procedures possible, sometimes it’s necessary to perform additional procedures during the postoperative period of a surgery.

When this happens, it’s often appropriate to 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). Read on for to see what our experts say about this modifier and the potential challenges to watch out for when you bring it into play.

Meet the Requirements for 78

In the simplest terms, you’ll turn to modifier 78 when the same surgeon, or a surgeon in the same practice and specialty, returns a patient to surgery and meets the following three special circumstances:

• The subsequent procedure falls within the global period of the initial surgery;
• The surgeon returns the patient to the operating room (OR); and
• The subsequent procedure is related to the initial surgery, such as a complication, but is not planned as a second part of the initial surgery.

“I use the rhyme 78-relate, and that pretty much says it all,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. Use modifier 78 if the patient requires a return trip to the OR that is directly related to a procedure that took place within the past 90 days (or applicable global period), she says.

Caution: If the physician performs an unplanned procedure during the global period at the bedside or office instead of the OR, the global period includes the service and you shouldn’t use modifier 78. “Often the quandary is whether the service was planned/ staged or unplanned, but related,” Hauptman says.

Understand the Impact Behind Intent

Like everything else however, there are a few subtle details that can make or break your coding. Even if the procedure is related to the original, modifier 78 might not be the best choice. If you find yourself facing details having to do with whether the service was panned, unplanned, or staged (and that detail should certainly be included in the documentation), you may end up scratching your head about whether 78 is appropriate. At that point, two other modifiers may come into play:

Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period): If the surgeon performs a planned related procedure, such as an anticipated second stage of the initial procedure, you should use modifier 58 instead of 78.

Modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period): If the procedure is totally unrelated to the procedure within the last 90 days, you should use modifier 79, and that would set a new global period in motion for the second procedure, Hauptman explains.

Expect Some Payment Challenges

When you report modifier 78, you should expect less pay for the procedure than you’d get for the unmodified code.

“Modifier 78 results in reduced reimbursement because there is not a new global period,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. Pricing for CPT^® global codes includes work expected during the global period. The reduced pay applied with modifier 78 reflects the fact that only the intraoperative part of the reimbursement is compensated, Bucknam explains.

Test Your Understanding

The following examples should help exemplify proper use of modifier 78 in your gastroenterology practice:

Scenario: The surgeon performs a small intestine resection for a patient with a section of necrotic bowel in the jejunum. After clamping the proximal and distal margins, the surgeon resects the involved bowel, then constructs an anastomosis.

Two days following the surgery, the patient presents with a fever and bowel tenderness. The same surgeon returns the patient to the operating room to reopen the recent laparotomy and perform a complete washout due to a peritoneal infection.

Coding: Report the first procedure as 44120 (Enterectomy, resection of small intestine; single resection and anastomosis). For the reopening and cleaning of the surgical site two days following the initial surgery, report 49002 (Reopening of recent laparotomy) with modifier 78.

Note that for endoscopic procedures, it would be rare to report modifier 78, since endoscopic procedures have zero global days. An exception might be where a patient develops post-polypectomy bleeding, returns to the hospital, and during the same calendar day, is brought back to the endoscopy unit and undergoes colonoscopy with control of bleeding. This would likely call for 45382 (Colonoscopy, flexible; with control of bleeding, any method).

Scenario: Your gastroenterologist performed a colonoscopy at 9 a.m., but the patient returned to the endoscopy lab at 3 p.m. to control a bleeding polypectomy site in the ascending colon. The same gastroenterologist performed both services.

Coding: You should use code 45382 (Colonoscopy, flexible; with control of bleeding, any method) for the colonoscopy procedure. Append modifier 78 because it indicates that complications arose that necessitated a return trip to the OR.

Control of bleeding is an integral component of endoscopic procedures and is not separately reportable. If it is necessary to repeat an endoscopy to control bleeding at a separate patient encounter on the same date of service, the code for endoscopy for control of bleeding is separately reportable with modifier 78 indicating that the procedure required return to the operating room (or endoscopy suite) for a related procedure during the postoperative period. Quite commonly, payers will require review of documentation before paying an endoscopic service claim with 78 modifier.

Note: If the patient comes in bleeding on a different calendar date, you don’t need the modifier, since the endoscopy is a zero-day global service.