Orthopedic Coding Alert

Master similar modifiers to avoid confusion.

Modifiers are important additions to your codes that, when appended correctly, can accurately represent the total costs of your provider. Modifier 78 is no exception. Look at its definition below:

• Modifier 78 (Unplanned return to the operating/procedure room by same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period)

Using this modifier, however, can be tricky. Here are some dos and don’ts for using modifier 78.

Do This: Expect Limited Reimbursement

When using modifier 78, payers will reduce your expected payouts. In cases when you are coding for the second procedure, be prepared to collect only a portion, — about 80 percent — of the actual cost. This happens because the orthopedic surgery is divided into three payment periods. These include the preoperative phase, the operative phase, and the postoperative phase.

Modifier 78 reduces the reimbursement because when you file claims like this, you are only reporting for the operative phase since, typically, you have already collected the fees for the other phases. The payout varies, but as stated before, modifier 78 equates to roughly 80 percent of the total cost. Always report the actual cost, and let the payer work out the difference.

Do This: Code for a Separate Surgery

Modifier 78 signifies that a new surgery is taking place. This means that you should code for an entirely new operation.

Example: A patient presents with a closed supracondylar humerus fracture. The orthopedist performs manipulation, which you report with 24535 (Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction). The fracture displaces and the patient returns for internal fixation with open treatment without intercondylar extension. You’ll report 24545 (Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension) and append modifier 78.

However, you should be paying attention to the level of care a surgeon provides. Some cases, included inflections, can be treated without going to the operating room. If no follow up operation is performed, then you cannot use modifier 78. Modifier 78 is reserved for surgery only.

Don’t Do This: Confuse Modifier 78 and Modifier 58

Many coders confuse modifier 78 and modifier 58 because they both involve follow up procedures. However, misuse of either modifier will result in denial from auditors. Look at the definition:

• Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period)

The important words to extract from the definition are staged and related. In cases when modifier 58 is appropriate to use, the physician plans the follow up procedure for a time within the procedure’s global period. This means that they have anticipated a secondary procedure. For that follow up procedure, append modifier 58.

Example: The orthopedist manipulates a patient’s ulnar fracture. An X-ray at the follow-up appointment shows that the reduction failed, so the physician completes pinning or an open reduction with internal fixation (ORIF). Code the procedure as needed (with 25545, Open treatment of ulnar shaft fracture, includes internal fixation, when performed, for example) and append modifier 58.

Modifier 78 is largely used to report unplanned returns to the operating room. This means that following the initial procedure, an unplanned complication occurred and the patient was taken in for a new operation. Consider the example from earlier. If the fracture originally manipulated by the orthopedist (coded as 24535) is displaced, then this primary operation led to an emergency procedure to be coded as a separate operation appended with modifier 78. Your code will look like this: 24545-78.

Don’t Confuse Modifier 78 and Modifier 79

Modifier 78 implies that the follow up procedure was directly related to the initial operation. Considering the example from earlier, the displacement followed the original manipulation. For any case when the new procedure is inherently caused by the initial encounter, use Modifier 78.

Modifier 79 is a little different. Look at the definition below:

• Modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period)

This definition indicates that the procedure was not related to the initial encounter. For example, your surgeon performs total knee replacement for Mrs. Brown. A few weeks later she comes to the office with aseptic bursitis of the right elbow (M70.21,  Olecranon bursitis, right elbow). The physician completes bursectomy (24105, Excision, olecranon bursa). You’ll append modifier 79 because the bursectomy is unrelated to the original knee replacement procedure and has a different diagnosis.

Don’t Do This: Ignore Your Diagnosis Coding

The reason for the return to the operating room is not the same as the reason for the original surgery. For infection, for instance, you should link an appropriate diagnosis, such as T84.52XA (Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter) to the procedural code and follow the ICD-10-CM instruction to report an additional code to identify the infection.

And remember that the global period stays with the original case. Payers will not “reset” the global period when you report a procedure with modifier 78, expertssay.

So if a complication occurs 20 days into a 90-day global period, only 70 global days remain after the return to the operating room.