General Surgery Coding Alert

When the service you wish to report doesn't quite meet the standards for applying modifier 78 (Unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period), consider these modifier alternatives to meet your coding needs.

- For follow-up procedures during the global period that are related to the patient's initial condition, you would append modifier 58 to the appropriate procedure code, explains Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board.

Remember, modifier 78 applies when the patient treats a different condition -- that is, a complication -- related to the initial surgery. Furthermore, modifier 58 denotes a planned or anticipated procedure, whereas modifier 78 "is to be used for unplanned procedure(s) by the physician who performed the initial procedure," according to the AMA's CPT Assistant (vol. 18, issue 2, February 2008, page 4).

Learn more: See "Look to Underlying Condition When Applying Modifier 58," General Surgery Coding Alert, vol. 10 no. 12, pages 91-92.

- If the surgeon repeats exactly the same procedure during the global period (in other words, if you would report the second procedure using the same CPT code as the first procedure), you should append modifier 76 (Repeat procedure by same physician) rather than modifier 78.

Example: A patient with an aortofemoral bypass graft presents with reduced circulation to his leg. A CT scan indicates that the graft has thrombosed (996.74). The surgeon performs thrombectomy (35875, Thrombectomy of arterial or venous graft [other than hemodialysis graft or fistula]) and admits the patient for observation.

Four hours later, the patient again exhibits signs of reduced circulation. A follow-up CT indicates that another clot has formed at the same location. The surgeon again performs thrombectomy and follows with more aggressive anticoagulation.

In this case, you should report 35875-76 for the repeat thrombectomy by the same physician.

- For a procedure during the global period that is not related to the previous surgery or the underlying condition that prompted the initial surgery, you should access modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

In other words: If the same surgeon must perform a distinct, unrelated surgery -- including all follow-up -- for an unexpected medical condition during a previous procedure's global period, you should append modifier 79 to the subsequent procedure code(s). You must always submit separate, distinct ICD-9 codes for the subsequent surgery to demonstrate medical necessity and show that it is unrelated to the initial surgery.

Example: Your surgeon performs a modified radical mastectomy and axillary node dissection (19307, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major musle).

The patient then sees an oncologist, who recommends chemotherapy. Because the patient's peripheral veins cannot handle chemotherapy delivery, the oncologist asks your surgeon to implant a venous access device (for example, 36571, Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older).

Because the CVA insertion during the global period is unrelated to the mastectomy, you may report 36571 separately by appending modifier 79.