Otolaryngology Coding Alert

Question: The patient had an I&D which we coded with 69005. She returned five days later for another 69005 in the same area. Would it be appropriate to append modifier 58 to the code? I also wondered about modifier 78 since the second visit was unplanned.

Nebraska Subscriber

Answer:

If there was no complication associated with the second use of 69005 (Drainage external ear, abscess or hematoma; complicated), then you cannot use modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Instead: Even though the second treatment was unplanned, if the original I&D did not lead to the surgeon’s desired outcome and you are still within the global period, you would include modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) on the second claim. Modifier 58 is appropriate because the physician is attempting to reach the desired outcome using conservative measures.

One of the key factors in selecting the 58 modifier is determining that the surgeon is treating the same problem that was treated by the first surgery. If you’re coding for a patient who returned to the OR for a complication resulting from the first surgery (not the problem that led to performing the original surgery), you would use modifier 78 instead.