Podiatry Coding & Billing Alert

Coders can expect reduced payment for any modifier 78 claims.

Sometimes your podiatrist must perform an unplanned procedure during a patient’s postoperative period. In this case, you must check the medical documentation to see if the claim warrants a modifier, namely 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).

Read the following tips to make sure you always know when to append modifier 78.

Tip 1: Observe When to Correctly Append Modifier 78

One coding expert has made an easy mnemonic device out of modifier 78, which helps explain when to use it.

“I use the rhyme 78-relate, and that pretty much says it all,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “If a patient requires a return trip to the OR [operating room] that is directly related to a procedure that took place within the last 90 days, the 78 modifier is appended.”

There are several instances in which you might use modifier 78, but the important elements of each encounter are whether the service was related to the original surgery and whether or not the surgeon returned the patient to the OR.

“Often the quandary is whether the service was planned/staged or unplanned, but related,” Hauptman says. “A staged procedure would be a 58 modifier [Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period], while the 78 is for that unplanned trip. Keep in mind that it must be trip to the OR. If another procedure is needed and performed at the bedside or in the office, it cannot have the 78 appended to it as it is included in the global surgical package.”

Tip 2: Modifier 78 Equals Reduced Pay

Coders can expect reduced payment for any modifier 78 claims, experts say.

“Modifier 78 results in reduced reimbursement because there is not a new global period; only the intraoperative part of the reimbursement is paid,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Tip 3: Differentiate Between Modifier 78 and Modifier 79

Sometimes coders may mix up modifier 78 with modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period), but you don’t have to fall into this trap.

As 78 is for related procedures, modifier 79 “is for procedures performed that are unrelated to the one performed within the last 90 days [the original global surgical period],” Hauptman says. “If the procedure is totally unrelated, the 79 would be appended, and a new 90-day global period would be set in motion around the second procedure.”

It’s important to remember that the second procedure, the one with modifier 79, is unrelated, says Gregory Przybylski, MD, at the JFK Medical Center in Edison, New Jersey. It’s not a planned return for a staged procedure or a return to the OR for a complication or other related procedure. Therefore, a new ICD-10 code would be expected to be reported with the second unrelated procedure.

Tip 4: Answer 3 Questions Before Using Modifier 78

When you are looking through your surgeon’s medical documentation, you can ask yourself three questions before appending modifier 78. If you can answer “yes,” to all three questions, then the situation may warrant a modifier 78.

The podiatrist performed surgery for an elongated metatarsal, which consisted of an oblique distal osteotomy with a single screw fixation. 40 days later, the patient slipped on a step, which displaced the osteotomy and pulled the screw out. The podiatrist had to return the patient to the OR to remove the screw, realign the osteotomy, fixate the bone, and immobilize the patient in a BK cast.

Is the subsequent procedure related to the initial surgery? Remember, you can only append modifier 78 if the surgeon undertook the subsequent surgery because of complications from an initial surgery. You can answer “yes” for this example because the subsequent surgery, the displaced osteotomy and pulled screw is related to the original surgery, the first osteotomy with screw fixation.

Does the procedure fall within a global? Remember, the subsequent surgery must occur during the 90-day global period of the initial surgery. For this example, the podiatrist performed the subsequent surgery 40 days after the initial surgery, so you can answer “yes,” to this question.

Lastly, was there a return to the OR? Remember, the subsequent surgery requires a return to the OR. In the documentation, it states that the podiatrist returned the patient to the OR to treat a complication of the original skull base procedure, so the answer to this question is “yes.”

Solution: Since you can answer “yes,” to all of the three questions above, you should report 28322 (Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft)) with modifier 78 appended.