Revenue Cycle Insider

Question: I have an operative report for a thyroid lobectomy procedure. Following the procedure, the patient complained of difficulty swallowing and hoarseness when speaking. The same surgeon returned the patient to the operating suite and performed a diagnostic laryngoscopy to examine the patient’s vocal cords.

Should I append modifier 78 or modifier 79 to 31575 for this scenario?

Revenue Cycle Insider Subscriber

Answer: 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 31575 (Laryngoscopy, flexible; diagnostic) on the claim.

The surgeon deemed the patient’s complaints of hoarseness and difficulty swallowing medically necessary to warrant a laryngoscopy. The symptoms could be considered complications from the thyroid lobectomy, which would back up the medical necessity of the laryngoscopy and permit the use of modifier 78. You’ll append modifier 78 when the physician was not planning to perform an additional procedure, but the second intervention is related to the initial operation.

Modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) is an incorrect modifier choice because the surgeon hadn’t planned to return to the surgical suite to examine the patient’s vocal cords. Append modifier 79 when the provider performs a procedure that’s unrelated to the initial surgery.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC