Otolaryngology Coding Alert

Question: A patient had surgery for bilateral partial thyroid lobectomy (60210-50), with a diagnosis of thyroid nodule. At the time of surgery, there was no signs of malignancy of the nodules. But when the permanent pathology returned, it showed invasive follicular thyroid malignancy. Therefore, additional surgery was needed and a 60260 was performed. This occurred within the 90-day global period of the initial surgery. Would it be correct to use modifier -78 on this procedure? Kentucky Subscriber Answer: The fact that 60210 (Partial thyroid lobectomy, unilateral; with or without isthmusectomy) and 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid) are related procedures and that 60260 was performed in the operating room makes a good case for using modifier -78 (Return to the operating room for a related procedure during the postoperative period). But modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) would be a better choice because the situation described is a classic example of a staged procedure and qualifies as more extensive. The otolaryngologist did not know a malignancy existed, so less (rather than more) tissue was taken during the first procedure.

When the cancer diagnosis was returned, a more radical procedure was performed. Modifier -78 is usually taken to mean the patient returned to the operating room because of a complication. For that reason, Medicare covers only the intraoperative portion of the second procedure and will not pay for the preoperative or postoperative components. If the procedure is appended with modifier -58 (as it should be in this case), 100 percent of the fee should be paid.