Modifier 78, multiple procedure reduction on same day as primary surgery?

[shelli.hester@pehp.org]

I have a situation where a surgeon billed 27130, the procedure was completed and the patient was taken to the recovery room. Post op x-ray found femur stem penetrating and dislocated. He was taken back to the OR for a revision on the same day and billed 27138.78. Would a multiple procedure reduction apply in this case?

 

[thomas7331]

In theory it should not, since the purpose of a multiple procedure reduction is that the costs of performing a second procedure are lower when the two are done in the same operative session. But some payer reimbursement policies do specify that the multiple procedure reductions will apply to any two procedures done on the same date of service.

I'd check your payers policy language and see. If it states that it only applies to a single operative session, then you may be able to appeal with documentation if they take a reduction.

 

[mgarciaManagement]

My doctor is an OB/Gyn and she just used a modifier 78 for a Vaginal delivery that later had a retained placenta of which she had to do a D & C. So she billed 59400 along with 59160-78. Cigna paid the delivery and denied the D&C as incidental to the primary procedure. Is there any way this could have been covered??

 

[thomas7331]

59160 is not incidental to 59400 under NCCI, so I can't say for sure why this denied - Cigna may either be using their own internal policy or have made an error. You may need to review their policies or contact them to get more information. If they consider it incidental, and the documentation in fact support that this was done in a separate operative session on the same day, a modifier 59 or XE may be appropriate and might get the service paid. Or, you may need to submit an appeal if they still feel that the service is incidental and you disagree.

 

[mgarciaManagement]

59160 is not incidental to 59400 under NCCI, so I can't say for sure why this denied - Cigna may either be using their own internal policy or have made an error. You may need to review their policies or contact them to get more information. If they consider it incidental, and the documentation in fact support that this was done in a separate operative session on the same day, a modifier 59 or XE may be appropriate and might get the service paid. Or, you may need to submit an appeal if they still feel that the service is incidental and you disagree.

Thank you for your response. I will definitely look into these suggestions. Thanks again!!