Orthopedic Coding Alert

Modifiers that are close by in the CPT^® book aren’t always too similar.

So it is with modifiers 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) and 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). While they’re listed right next to each other in the CPT book, you use them for much different purposes when applying them to real-world coding situations.

We’ve got three experts to walk you through the ins and outs of using both modifiers, so you don’t trip the next time you’re preparing a 78 or 79 claim.

Return to OR Marks 78

Simply put, when the patient returns to the operating room (OR) during the global period of another procedure for a complication or other unanticipated problem, you would use modifier 78 to separate the second surgery, says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

78 deep dive: “If a patient requires a return trip to the OR that is directly related to a procedure that took place within the last 90 days, the 78 modifier is appended,” Suzan Hauptman MPM, CPC, CEMC, CEDC, assistant vice president, compliance coding, documentation and audit at Cancer Treatment Centers of America in Zion, Illinois. “Often the quandary is whether the service was planned/staged or unplanned, but related. A staged procedure would be a 58 modifier [Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period], while the 78 is for that unplanned trip.”

And payers are serious about that OR return, Hauptman warns. “Keep in mind that it must be trip to the OR. If another procedure is needed and performed at the bedside or in the office, it cannot have the 78 appended to it as it is included in the global surgical package,” she says.

Quick list: Consider this list of when NOT to use modifier 78 from Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania:

• When the procedure is planned or staged during a previous procedure.
• When the procedure is unrelated to the previous one.
• When the procedure doesn’t occur in the postoperative period.
• When the procedure isn’t performed in the operating room. (An OR can include an endoscopy suite, cardiac catheterization suite, or a laser suite.)

Use 79 for Unrelated Procedures

Modifier 79 is for procedures performed during the global period that are unrelated to the initial procedure and within its global period. If the procedure is totally unrelated, append modifier 79 and a new 90-day global period would be set in motion around the second procedure.

Providers use modifier 79 much less frequently than modifier 78. “Often an unrelated procedure during the global period would be performed by a different specialty and no modifier is appropriate but if the same surgeon, or other surgeon in the same practice and specialty, operates for an unrelated procedure, modifier 79 is used on the second procedure,” explains Bucknam.

Consider this example from Bucknam:

A young man falls and breaks the shaft of his right tibia. The orthopedist performs open reduction. Two weeks later, the same young man trips while going down the stairs with his new cast and breaks his left ulna. He returns to the same orthopedist, who performs open reduction of this new fracture during the global period of the previous procedure. The procedures are completely unrelated.

For this claim, you would report:

• 27758 (Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage) for the first surgery
• Modifier RT (Right side) appended to 27758 to indicate laterality
• 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed) for the second surgery
• Modifier 79 appended to 25545 to show that the second surgery was completely unrelated to the first one
• Modifier LT (Left side) appended to 25545 to indicate laterality.

Consider Falbo’s examples of when NOT to use modifier 79:

• When the two surgeries are related.
• When the operation happens outside the post-op period.
• When the procedure is performed somewhere other than the operating room.