Neurosurgery Coding Alert

Return to the OR is a must If you want to be sure when you should apply modifier 78 -- instead of similar modifiers such as modifier 58 and modifier 79 -- you need only ask yourself three questions. If all the answers come up "yes," you are safe to assume that 78 is your modifier of choice. 1. Does the Procedure Fall Within a Global? You would only apply 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) if a subsequent procedure by the same surgeon falls within the global period of an earlier surgery. For instance, you might apply modifier 78 for a procedure that occurs on day 30 following a major surgery with a 90-day global period. Note that modifier 78 is not the only modifier that may apply for procedures during the global period. You must satisfy two more conditions before you can select modifier 78 confidently. 2. Is the Procedure -Related- to the Initial Surgery? When appending modifier 78, you should be sure the available documentation substantiates that the surgeon performed the subsequent procedure due to conditions arising from the initial surgery. AMA instructions from CPT Assistant (Feb. 2008, page 3) stress, "When using modifier 78, the procedure is - directly associated with the performance of the initial procedure." In other words: You should append modifier 78 when coding for the surgeon's treatment of a complication(s). A complication may be related to the initial procedure, but it is not necessarily related to the patient's initial condition, affirms Jo Ann F. Kergides, CPC-H, physician services coder at UMDNJ-SOM Vascular Surgery in Stratford, N.J. Tip: If the medical record does not indicate clearly the reason for the subsequent surgery, you should check with the operating physician prior to selecting a modifier. Example: The surgeon removes spinal instrumentation (for example, 22852, Removal of posterior segmental instrumentation) during the global period of the initial placement (such as 22842, Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments) because the patient's body rejects the device. In such as case, because the complication is related to the initial surgery (although, again, the complication is not related to the condition that prompted the surgeon to place the instrumentation initially), you would report 22852 with modifier 78. 3. Is There a Return to the OR? Finally, the subsequent procedure must require that the surgeon return the patient to the operating room (OR), explains Maggie M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. You cannot append 78 if the physician [...]