Modifier 79 or 58

JJOHN0312

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We have some recent denials back from NGS for 64721. It is in a postop of 64721, done on the opposite side as the global procedure. Would you bill with 58 or 79? They are denying the 79? So, 64721-LT done on March 15th and 64721-78-RT done on May 15th. I mean, I guess it is kinda related/anticipated. What you do you all think?

Thanks,

J
 

twizzle

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The procedure on the right side cannot be considered related to the original procedure performed on the left. They are different structures. You say 64721-78-RT was performed on 5/15 yet you say they are denying the 79. So was it billed with 78 or 79? Modifier 79 would be the correct modifier to append to indicate an unrelated procedure, not modifier 78.
 

b.cobuzzi

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It is a staged procedure. Since you cannot perform both sides at one operative session, your doctor planned to stage the surgeries, doing one on 3/15 and one on 5/15. I would use the 58 modifier. You are not doing the second side because of a complication so I would not use the 78 modifier.
 

twizzle

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I disagree with using 58. A staged procedure is an extension (for want of a better word) of an initial procedure that is performed at a later date. A procedure performed on one side of the body cannot be considered an extension of a procedure performed on the other side.
I think modifier 79 is correct. The procedures are not related.
 

b.cobuzzi

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JJOH0312 can try to appeal the denial of the 79 modifier from NGS or they can send in a corrected claim with the 58 modifier. Payers are considering surgeries related when the first 3 characters of the diagnosis are same and the only differentiating character is the side digit(s). Calling the payer, asking them which modifier they expect in the situation does not work because you know they never give you the answer.
 
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