Orthopedic Coding Alert

Don't miss out on extra pay when global period resets.

Just because you routinely append modifiers to your claims doesn't mean you're filing correctly and getting the most appropriate pay. Brush up on your modifier know-how with these tips for three of the trickiest choices: modifiers 58, 78, and 79.

Remember All Possible Uses for 58

The descriptor for modifier 58 seems self-explanatory: Staged or related procedure by the same physician during the postoperative period. Coders sometimes trip, however, when they forget that modifier 58 actually applies to subsequent procedures that fall into one of three categories:

Planned or anticipated (staged): "A good example would be an infected hand that has to be debrided several times over the course of a couple of weeks," says Elisabeth Janeway, CCP, CPC, CCS-P, president of Carolina Healthcare Consultants in Winston-Salem, N.C. "You won't use a modifier on the first procedure, but will add modifier 58 on the subsequent procedures."

More extensive than the original procedure: 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.

•Therapy or treatment following a surgical or diagnostic procedure: This could apply to a soft tissue biopsy followed at a later date by malignant tumor excision, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network, LLC. Although knowing about the option is good for coders, Janeway points out that orthopedists rarely use modifier 58 in these situations.

Global tip: You'll only append modifier 58 to the second procedure if it occurs during the first procedure's global period. The date of the second procedure resets the global period.You should expect 100 percent reimbursement for procedures you file with modifier 58. Make sure you deserve the reimbursement, Janeway advises, before you append the 58.

Verify 'Surprise' Before Reporting 78

If your orthopedist completes a second -- but unplanned -- procedure related to the first, you might need modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). Before appending modifier 78, confirm that the follow-up procedure was relatedto the original procedure but unplanned and that it occurred during the global period.

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.

Pay change: Because the second procedure was related to the global procedure and was unplanned, the original procedure's global period stays intact. The second procedure's global period begins on the date of that surgery. Expect a reduction in pay for the second procedure, however " anywhere from 50 percent to70 percent of the allowable charge, experts say.

"Private insurers tend to pay more for procedures with modifier 78 than Medicare's typical 69 percent," Janeway says. "Make sure there was a return to the OR, especially for Medicare -- Medicare won't pay if the physician performs the procedure in the patient's room."

Check All Diagnoses to Justify 79

Sometimes a patient returns to the operating room for a procedure that's not related to the first surgery, but still within the first procedure's global period. In that case, you'll consider appending modifier 79 (Unrelated procedure or service by same physician in the postoperative period).

Caveat: Before reporting modifier 79, verify that your physician does not perform the second procedure because of complications related to the first. You must have a different diagnosis supporting the return to surgery and your use of modifier 79.

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 elbow (726.33, Olecranon bursitis). 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 adifferent diagnosis.

You should receive full reimbursement for the second procedure because a new global period starts with the unrelated procedure. "Each line item should get modifier 79 if the surgeon performs more than one unrelated procedure,"notes Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. And because you'll be dealing with multiple global periods, monitor follow-ups carefully to ensure you correctly track the patient's care.