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Urology Coding Alert

Use Correct Modifier for Second Surgery Within Global Period

Published on Wed Aug 01, 2001

When a urologist brings a patient back to the operating room (OR) within the global period of the first procedure, he or she may use one of three modifiers. Whether to use modifier -78 (return to the operating room for a related procedure during the postoperative period), modifier -79 (unrelated procedure or service by the same physician during the postoperative period) or modifier -58 (staged or related procedure or service by the same physician during the postoperative period) depends on the reason for the second procedure. The modifier you choose affects how much you will be paid for the second procedure.

Use Modifier -78 for Complications
 
If the patient returns to the OR for surgical treatment of a postoperative complication within the global period of the primary surgery, the urologist should bill the procedure that rectifies the complication. The coder must add modifier -78 to the second procedure to indicate that this was an operative treatment of a complication in the OR. The urologist will be reimbursed for only the intraoperative percentage of that procedure, with no fee for pre- or postoperative services. Using modifier -78 generally reduces the procedure fee of the surgery to 60 to 75 percent of the fee schedule. The urologist will not start a new global period with the second procedure.
 
For example, a urologist performs a transurethral resection of the prostate (TURP). The patient does well for three days until he starts bleeding. The physician brings the patient back to the OR and fulgurates the bleeding blood vessel within the prostatic fossa. Bill 52214 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) and append modifier -78. The urologist will not begin a new global period with this procedure.
 
Under Medicare rules, treatment for complications outside of an OR -- such as a hospital bed, an office or an emergency room -- is not a payable service and is included in the global package.
 
If the urologist treats a complication in the office, the coder can't bill it with modifier -78. For example, a patient who had a TURP and is bleeding three days later may come in for an office visit. The urologist places a catheter and irrigates the patient out. Because the procedure did not take place in the OR, the physician cannot bill for it.  
 
The urologist can use the same diagnosis for the first and second procedures. Modifier -78 does not require a separate diagnosis.

Modifier -79 for Unrelated Procedure
 
Use modifier -79 for an unrelated procedure performed during the global period of another procedure.
 
For example, a patient undergoes TURP and does well. The urologist sees him in the office a month later, and he has a stone blocking his ureter. The physician performs a ureteroscopy and stone extraction. Bill 52352 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) with modifier -79, which indicates a separate surgical procedure unrelated to the TURP. The practice will receive full payment, but the urologist must start a new global period (although in this example the global is zero days). Unlike modifiers -78 and -58, modifier -79 mandates a different diagnosis for the first and second procedures. The diagnosis code for the TURP is 600.0 (hyperplasia of prostate; hypertrophy [benign] of prostate). The stone-extraction diagnosis code is 592.1 (calculus of kidney and ureter; calculus of ureter).

Modifier -58 for Three Different Purposes
 
Coders can append modifier -58 for three purposes:
 
1. Staged second procedure. When the urologist performs a procedure within the global period that is part of the initial procedure (staged procedure), you can append modifier -58. For example, the urologist performs an ESWL (50590) for a large renal pelvic stone but realizes that a second ESWL will be needed within a month to fragment the stone completely. In the operative report, the physician should state prospectively that the second ESWL will be a staged procedure. The coder would bill the second ESWL one month later (within the 90-day global of the first ESWL) with modifier -58. Proper coding in this case is 50590-58.
 
Payment for the second ESWL will be full, but a new global period will start with the second ESWL, says Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stony Brook. Some urologists say that writing "This may be a staged procedure" in the operative report is necessary after every initial ESWL. The diagnosis code for the first and second procedure is 592.0 (... calculus of kidney).
 
2. Second procedure more extensive than the first. When the physician performs a more extensive procedure the second time, you can also append modifier -58. For example, the urologist performs an ESWL for a renal pelvic stone. After a month the physician realizes the stone was incompletely fragmented by the ESWL and decides to perform a percutaneous nephrostolithotomy, 50081. The diagnosis for both procedures is 592.0. The coder should bill 50081 with modifier -58 appended to the second procedure. Again, this will bring full payment for 50081, but a new 90-day global period would begin.
 
3. Second procedure follows diagnostic procedure. Performing a second procedure during the global period of a surgical diagnostic procedure also allows the coder to use modifier -58. For instance, the urologist performs a deep biopsy of a tumor of the penile shaft. He or she should code 54105, which has a 10-day global, for that initial procedure. On day three following the surgery, the biopsy reveals cancer of the penis, which will require a partial amputation. Bill 54120 (amputation of penis; partial) for the amputation, which is performed the next day. Because this is still within the global period of the initial surgery (54105), append modifier -58 to 54120. The physician will be paid the full fee and start a new 90-day global.

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