Orthopedic Coding Alert

Several CPT surgical modifiers exist for related or unrelated procedures and returns to the operating room (OR) during the global orthopedic surgical period. Yet even when complex orthopedic surgeries result in returns to the OR for complications or anticipated additional procedures, many physicians and coders do not pursue a great deal of reimbursement because they think any postoperative care that falls in the global period may not be billed separately. There are instances when additional billing within the global period is appropriate, and understanding the differences in global modifiers and knowing when to append them is essential to obtaining reimbursement.

Modifiers -78 (return to the operating room for a related procedure during the postoperative period), -79 (unrelated procedure or service by the same physician during the postoperative period) and -58 (staged or related procedure or service by the same physician during the postoperative period) are the CPT modifiers for any return to the OR or procedure conducted by the same physician during the postoperative period. These modifiers also apply when a different physician from within the same professional group, billing under the same tax ID number, treats the patient during the postoperative period.

1. Modifier -78. The rationale behind the -78 modifier is that every surgery includes a preoperative, intraoperative and postoperative component. When two procedures are performed within the same global period, carriers consider it essentially double dipping if they pay twice for global postoperative care.

An example of when to append the -78 modifier occurs when a patient has a total knee replacement (27447, arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee replacement]) that becomes infected post-operatively. The prosthesis is removed, and a temporary methylmethacrylate spacer may be placed between the femur and tibia. This secondary surgical procedure is reported using 27488 (removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee) with the -78 modifier to indicate the procedure was related to the original surgery.

The above example represents a clear-cut case of the use of -78, but other scenarios blur the lines of interpretation between modifiers -78 and -79. For example, if a patient has a total knee replacement (27447), then falls during physical therapy and does major damage to the prosthetic knee, he or she may have to return to the OR for a revision arthroplasty (27487, revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component). Per Medicares interpretation of the modifiers, the repair of the failed arthroplasty, because it is related to the original arthroplasty, would be coded with a -78 modifier. Yet some commercial carriers will accept the -79 modifier, because the fall was not a typical complication of surgery, but a separate event that affected the same knee.

According to BillieJo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopaedic and Sports Medicine, a six-office practice with 18 physicians in Cincinnati, some commercial carriers may accept the -79 modifier for the 27487 under the above circumstances. But McCrary feels -78 is the appropriate modifier. Because the return to the OR was necessitated by the original surgery, I feel that -78 is the modifier to append, although there are coders who would say that -79 is best, arguing that the fall is not related to the original TKR, McCrary says. In a gray area such as this, the carrier will ultimately determine how it interprets the scenario and the definition of the modifier.

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., explains that modifier -78 was created at the request of HCFA to respond to the requirements of Medicares global surgical package, which limits payment for procedures performed during the postop period to those treatments requiring a return to the OR and subtracts the amount calculated to be for the postoperative portion of the global package. It is important to make a distinction not only between modifiers -78 and -79 but also between payers. Medicare considers any procedure that involves the original injury, procedure or operative site as related to that original surgery, and will accept modifier -78 for those procedures that require a return to the OR. Commercial carriers, however, may consider a post-operative procedure to be related to the complication and unrelated to the original procedure, allowing payment without reduction using the -79 modifier attached to the procedure code. In this context, commercial carriers may even pay for treatments for postoperative complications in the office or at bedside (with the use of modifier -79), rather than limiting the payment to those services provided in the OR (modifier -78).

It is important for coders to remember that the -78 modifier signals a physical return to the OR, not a minor in-office surgical procedure. Even if the return to the OR is on the same day as the initial surgery, the procedure needs to be unanticipated. Also be aware that the -78 modifier may trigger the start of a new global period by some non-Medicare carriers.

2. Modifier -79. According to McCrary, the most straightforward use of modifier -79 is for procedures that are entirely unrelated to the original surgical procedure. You would use this modifier when the patient had knee surgery, then returned within 90 days to have an injection for carpal tunnel syndrome. Callaway adds that -79 also comes into play more often in trauma cases, where there may be injury to multiple body parts. For an accident victim, you could potentially do surgery on one knee, then operate on another limb a few days later. The injuries are at two different areas of the body and therefore unrelated to each other, she says.

3. Modifier -58. This modifier indicates that the additional procedure or service inside the global period was planned at the time of the original surgery, a more extensive procedure than the original surgery or for therapeutic purposes after a diagnostic procedure. Because modifier -58 should not result in a reduction from the carrier, practices need to be careful of the wording they use with the modifier, and the manner in which they use it. Whenever possible, surgeons should indicate in their operative note that there is a certainty or at least a strong probability that additional procedure(s) will be required. But -58 cannot be used as a what if modifier, meaning that it would be inappropriate to record in the note, if infection develops, we will return to OR for debridement. McCrary uses the -58 if a patient returns to the OR for multiple debridements of a contaminated wound related to a fractured patella that was repaired using an open reduction (27524, open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair). If the knee is already infected at the time of the reduction, you know you will bring the patient back, and keep bringing him or her back until the infection is fully resolved, he says. The op note should indicate that the infection was present and that additional debridement (11000-11044) under anesthesia was anticipated.

Reductions Still Happen

Although coding experts agree that reductions should not occur when the -79 or -58 modifier is appended, they still do. Callaway recommends checking with different carriers to see what modifier they will accept in a given situation. With reimbursements staying flat and expenses on the rise, any appropriately applied modifier that identifies extra work to the payer is worth pursuing. Submit the claim for the post-op procedure with a separate ICD code that is related to complication and see what happens, Callaway says. Unfortunately, not only is there a lack of clear guidelines for use of and reimbursement with these modifiers, but the guidelines from carrier to carrier are contradictory, depending on payer or condition.

For Medicares specific guidelines for use of modifiers during the global surgical period, look in section 4820 of the Medicare Carriers Manual Part 3, or review policy on-line at www.hcfa.gov/pubforms/14_car/3b4820.htm#_1_8.