Otolaryngology Coding Alert

Correctly indicating to a payer how a service or procedure is related or not to another surgery can make the difference between reimbursement for the second treatment and denial. Sorting out which postoperative modifiers apply in a certain situation, however, can prove more gray than black and white. Consider each modifier's role to determine if your "related" services knowledge stacks up. Compare Related to Staged When separately reporting postoperative services that are not included in the original procedure's global package, you must decide if the follow-up service is related to the primary surgery. Because procedures can be related in different ways, choosing the appropriate modifier can prove elusive, says Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus and head and neck practices in metro Atlanta. For instance, modifiers -58 (Staged or related procedure or service by the same physician during the postoperative period) and -78 (Return to the operating room for a related procedure during the postoperative period) refer to related procedures. The description "return to the operating room" may tempt you to think that modifier -78 applies to secondary procedures that occur in the operating room and that modifier -58 refers to services that take place in other locations. But this division based on site of service is not correct. Use Modifier -58 in 3 Subsequent-Surgery Situations The difference instead is based on whether the otolaryngologist planned or anticipated that he or she may need to perform a second procedure at the time of the initial surgery, or the subsequent surgery is more extensive. If the subsequent surgery is planned and staged, you should use modifier -58. The otolaryngologist may sometimes perform one part of a complicated surgery at one session and then finish the procedure a week later, says Jay B. Horowitz, MD, clinical assistant professor of surgery/otolaryngology at Robert Wood Johnson Medical School in New Jersey. In this case, you must append modifier -58 to the second procedure to break the global period of the initial procedure. To use modifier -58 during the postoperative period, make sure the second procedure meets one of the following criteria:

1. planned at the time of the original procedure (staged)
2. more extensive than the original procedure
3. for therapy following a diagnostic surgical procedure. Physicians often initially perform less extensive procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "The American Medical Association created modifier -58 in part to encourage physicians to provide the most conservative care possible leading to more drastic interventions, when necessary." Without modifier -58, doctors would have no way to recoup [...]