Modifier 58/78 for multiple surgeries for osteomyelitis

Ccgerson

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I'm a little confused what modifier to use in this instance: The patient has chronic osteomyletis of tibial plateau/ knee, after a traumatic injury requring ORIF tibia a year ago. He has diabetes and other comorbities that put him at risk for OM. HE's been the OR 4 times in the past year. This time, he is admitted for I&D knee (debridement of bone/ tibial plateau - CPT 11044). Is this modifier 58 or 78? Can his recurrent infections be considered compications, if it's in large part due to his comorbidities? My co-worker has been using modifier 58 for previous surgeries. That' s my first question, which modifier to use for this surgery.
Second question- The patient then has another more extensive surgery 2 days after the debridement, 27310- with a 90 day global. The debridement 2 days earlier has no global. Do I use a modifier for this second surgery?
I think I should use 58 for first surgery and subsequent surgery, but not positive.
Thank you!
 

JEYCPC

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58 is for a staged or planned procedure. It should be documented in the op notes for the first procedure that it is planned. Was it planned?
 

amyjph

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Is your question asking if you should append a 58 vs. 78 on the debridement code 11044? Is the patient currently in a global post op period for anything at the time the 11044 is being done? If no, you don't put either of those modifiers on it. They would only be appended to tell insurance that this surgery is either staged or related (58) or unplanned return for a complication (78) to the surgery in global.

The second part I think you are asking is if you should append a 58 vs. 78 to the 27310? If the patient is not in a global for anything else, the 11044 has 0 post op days so you would not put a modifier on the 27310 either.

If the patient is in a global for something at the time the 11044 is done, then you have to decide if that subsequent surgery was staged/related to the prior one or if it is a complication & unplanned return to the OR.

Does that make sense?
 

Ccgerson

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None of the surgeries after the initial ORIF tibia were "planned". He's had multiple debridements due to recurrent infections, osteomyelitis. This most recent surgery is in the global period for a previous arthrotomy for knee joint I&D (27310). Is this considered a complication? Is the provider penalized by getting reduced payment due to the patient's increased risk of infection, which is unpreventable from the physicians perspective? Maybe I'm overthinking this. Technically, it's not "planned", although it is "anticipated" (due to the patient's poor healing status d/t uncontrolled diabetes), The description for modifier 58 does state the subsequent surgery must be either planned, anticipated, or more extensive than prior surgery.
 

mhstrauss

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None of the surgeries after the initial ORIF tibia were "planned". He's had multiple debridements due to recurrent infections, osteomyelitis. This most recent surgery is in the global period for a previous arthrotomy for knee joint I&D (27310). Is this considered a complication? Is the provider penalized by getting reduced payment due to the patient's increased risk of infection, which is unpreventable from the physicians perspective? Maybe I'm overthinking this. Technically, it's not "planned", although it is "anticipated" (due to the patient's poor healing status d/t uncontrolled diabetes), The description for modifier 58 does state the subsequent surgery must be either planned, anticipated, or more extensive than prior surgery.

IMO, infection would be considered a complication, and you would therefore use modifier 78. This does result in a reduction in payment to the subsequent procedure--the payer will likely only pay the "intraoperative" portion (per the RVU files), BUT the global period will not reset; the global period will end based on 90 days after the original surgery. If modifier 58 is used, the payer should pay the full amount of the subsequent procedure, but the global period will be extended to 10/90 days after the subsequent procedure, depending on it's global period.

Here's a good article referencing CMS:

http://www.emblemhealth.com/en/Prov...n-Unplanned-Return-to-the-Operating-Room.aspx

HTH!
 

Ccgerson

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So, I would put modifier 78 on the first procedure - 11043. This code has no global . What about a subsequent surgery (same hospitalization) 2 days later - 27310.
 

mhstrauss

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So, I would put modifier 78 on the first procedure - 11043. This code has no global . What about a subsequent surgery (same hospitalization) 2 days later - 27310.

If the 27310 is still within the global period of the original surgery, then it will need a modifier also....78, if it is also a complication.
 

Ccgerson

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Periprosthetic hip fracture under global

Now I have another one, this a little different. The patient had a total hip replacement 2 months ago, fell and sustained a periprosthetic hip fracture. He had a total hip revision, femoral component - 27138. He's still under the global from hip replacement. :eek: Is this considered unrelated or a complication?
Thank you!!
 

AlanPechacek

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Periprosthetic femur fracture treatment

The periprosthetic femur fracture is a new problem, even though it occurred within the Global time frame for his index procedure (THA: 27130). The surgical treatment of the periprosthetic fracture is fracture care, not "revision" surgery for his THA, i.e. there was not any inherent problem or complication of the THA itself, such as recurrent dislocation, infection, loosening, etc. that led to his reoperation. The "revision" of the femoral component was fracture care. Most periprosthetic fractures of the femur are in the subtrochanteric or proximal shaft regions, occasionally up in the intertrochanteric region. Your query doesn't say exactly, but my best guess is upper shaft, and was treated by removing the original femoral component with a relatively short stem and replacing it with a long stem femoral component to get past the fracture, and may or may not have required supplemental fixation (cables, wires, cement, etc.). Your surgeon may have called it a "revision," but in reality, it was Open Treatment of a Femoral Fracture with Internal Fixation (either 27245 or 27506 depending on the location of the fracture). Modifiers might be added such as 22 for Increased Procedural Services for having to remove then replace the femoral component, &/or 78 for 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. Both may apply.

By the way, the coding for Periprosthetic fractures based on the recommended coding changes for 2017 is being changed to a M97 Code Set, and deleted from the T84.0(4) Code Set.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
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