Orthopedic Coding Alert

Question: The surgeon performed arthroscopic knee surgery for a patient with symptomatic internal derangement of the knee. The surgery provided no relief for the symptoms, and a subsequent TKR was done later but still during the first postoperative period. Should the TKR be billed with modifier -58 or modifier -78?

Maine Subscriber
 
Answer: Although coders may disagree on this subject, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) is the best choice for this case. CPT indicates that modifier -58 is to be reported when a procedure performed during the global period of another procedure meets one of three criteria, one of them being that it be more extensive than the original procedure, which is true here. Do not use modifier -78 (return to the operating room for a related procedure during the postoperative period), because it is for a complication related to the original surgery. What you describe is not really a complication, but a lack of successful outcome with the first surgery. Therefore, something more extensive (the TKR) was required.