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prem_ponnuru

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Hi All,

Can anybody explain me which modifier is apropriate in the following scenario.

Surgeon has performed cpt 37765 on RT leg on 1st april 2009 and did the same procedure on 15th april 2009 on LT leg. Again he is repeated the same procedure on 30th april 2009 on RT leg for some mechanical complication (complication developed for both the legs)

04.01.09----37765-RT PAID
04.15.09----37765-LT DENIED 79
04.30.09----37765-RT DENIED 78/79

Now which modifier is to be used on the third claim 78 or 79.

My question is how should we select a modifier? based on paid claim or simply previous surgery even it got denied.

Thanks in advance.

Prem.
 
I would say the third one is a -78, since it's for a complication of the first surgery. Maybe the 2nd one could be a -58; was it "prospectively planned" at the time of the first surgery?
C.Martin
 
Not sure if this is the problem or not - but, the RT/LT modifiers should be "last"... not before the other modifiers (whichever you use);

04.01.09----37765-RT
04.15.09----37765.79.LT (change modifier position)
04.30.09----37765.78.RT (I'd use the 78, then the RT)
 
76 modifier - repeat procedure

If you are using the exact same procedure code on the exact same site within the global period, it is appropriate to use the -76 modifier.

I'd code
04.01.09 - 37765-RT
04.15.09 - 37765-79/LT
04.30.09 - 37765-76/RT

F Tessa Bartels, CPC, CEMC
 
76 modifier is used for a procedure repeated on the same day not anytime with in the global. The rule for modifiers is use the modifier which affects reimbursement the most first. The 79 affects the reimbursement more than the LT so it will goe first, the third scenario should be the 78 with RT modifier.
 
Tessa, I think you're right! (I stand corrected) ;) If that third procedure (second one on the RT leg) is the exact same as the first one on the right leg,... if it's a repeat procedure the 76 modifier should be used - not the 78.

I'm just tossing this out there (because I don't know)... but, if it's on the same leg, different sites/veins...would it still be considered "repeat" because it's the same type of procedure on the same leg, or would it have to be the same sites/veins? AND, the same amount of incisions?.... (like they can't do 10 incisions the first time, and only 1 the next ...right?, they'd have to do the same 10,...right?...... )

i don't know...maybe i'm thinking too much into this one. however it goes, the 76/78/79...whichever, comes before the RT/LT :) (we all agree on that)
 
Last edited:
Modifier 76

mitchellde said:
76 modifier is used for a procedure repeated on the same day not anytime with in the global. The rule for modifiers is use the modifier which affects reimbursement the most first. The 79 affects the reimbursement more than the LT so it will goe first, the third scenario should be the 78 with RT modifier.
Click to expand...


CODING WITH MODIFIERS: A Guide to Correct CPT and HCPCS Level II Modifier Usage, 2nd edition, by Deborah J Grider (copyright 2006) page 202:

Review of Modifier 76
1. Modifier 76 should be used for all procedures when the physician repeats the procedure the same or during the postoperative period. (emphasis added by FTB)2. The modifier indicates that the claim is not a duplicate bill, but is the same procedure that was performed earlier.
3. The procedure repeated must be the same procedure (same procedure code) by the same physician.
4. An explanation of medical necessity for the repeat procedure is required by many insurance carriers. (enter reason in narrative field in tiem 19 on CMS -1500 form)

F Tessa Bartels, CPC, CEMC
 
Hi All,

I agree that I can use 76/78/79 modifiers for repeat/related/unrelated procedures.

Here the second procedure was denied because of some reason. The global period is not yet started for that second procedure. Now based on which procedure I will have to select modifer?

If it is based on paid first procedure, I should append modifer 79 to the third procedure also.
If it is based on previous procedure (second procedure), I should append modifier 78. But the previous procedure was denied and global period is not yet started.

My question is how should we select a modifier? based on paid claim or simply on previous surgery even it got denied?

Prem.
 
37765 has a 90 day global

37765 has a 90-day global period so in your example BOTH the subsequent procedures fall in the original global period.

F Tessa Bartels, CPC, CEMC
 
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