Urology Coding Alert

Question: I code for an ASC, and my payer won't reimburse me for claims with modifiers 78 (Return to the operating room for a related procedure during the postoperative period) or 79 (Unrelated procedure or service by the same physician during the postoperative period). Should we appeal?

Answer: "An individual payer has the right to deny a claim if it is within their guidelines to do so, and with many self-insured plans out there, the guidelines vary greatly regarding this issue," says Stephanie Ellis, RN, CPC, owner of Ellis Medical Consulting Inc. in Brentwood, Tenn.

Most important issue: "The ASC's global period for all procedures performed in the facility is 24 hours," Ellis says. "Most of the procedures performed in ASCs have a global period of 10 or 90 days defined, which is the global period for the operating physician's claims--not the facility's claims."

Therefore, ASC coders will rarely need to use modifiers 78 or 79. One of the unusual cases when you'd use these modifiers would be if a patient had a procedure in the ASC and went to the recovery room to rest. While in recovery the patient started to hemorrhage, and the surgeon returned the patient to the OR to stop the hemorrhage.

"That is usually the only time that one of these modifiers would be needed," Ellis says. "If the patient goes back into the OR at the same ASC for a procedure the following day and it is past 24 hours since the ending of the first procedure performed the day before, the ASC does not need to append modifiers 78 or 79 to their claim.

"If the patient was taken back to the OR at the same ASC for a procedure within the 24-hour period after the first procedure was performed and the ASC used the 78 or 79 modifier and still had the claim denied, I would advise the ASC to pursue vigorous appeal procedures," Ellis says.