RFA during Post Period

lcole7465

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One of my doctors performed a Lumbar RFA (64635-LT, 64636-LT) and the insurance denied due to the global period. The same procedure was performed a week earlier on the Right side.

In reviewing this claim, I believe that this should have been billed with either modier -58 or -76.

Any input would be greatly appreciated..
 

thomas7331

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I would think modifier 79 would be more appropriate here since a different site is being treated. 58 is for a staged/related procedure - documentation would need to meet the definition of this in order to use modifier 58.
 

pscanlan

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I would think modifier 79 would be more appropriate here since a different site is being treated. 58 is for a staged/related procedure - documentation would need to meet the definition of this in order to use modifier 58.
I agree with your reasoning. Using -58 would imply that the original procedure was not finished in one day, not that a second anatomical area was treated. -79 would indicate a distinct service in the postoperative period.
 

dwaldman

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thomas7331,

When the provider did a left side radiofrequency ablation and previously in the week did right side procedure, I think it could believed that the other side was planned at the time of the original procedure but some reason they had to stage the other side. For modifier 79, you would have to be under the impression that the other side was not staged based on the original procedure that was performed. The fact they repeated the same procedure a week later would make one think they had the second procedure planned at the time of the original.


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Modifier 58 Fact Sheet
Published on Feb 09 2016, Last Updated on Jul 27 2018

Definition: Indicates a staged or related procedure or service by the same physician* during the postoperative period.

Appropriate Usage
To report a staged procedure planned at the time of the original procedure
When the staged procedure is more extensive than the original procedure
For therapy following a diagnostic surgical procedure
When performing a second or related procedure during the postoperative period.

________________________
Modifier 79 Fact Sheet
Published on Feb 09 2016, Last Updated on Jul 27 2018

Definition: Unrelated procedure by the same physician during the post-operative period.

Appropriate Usage
To describe an unrelated procedure performed during the post-operative period of the original procedure.
The two procedures are performed by the same physician
All procedure codes except those with XXX in the GLOB (global) field of the MPFSDB.
Used on services during the post-operative period starting the day after the procedure

Inappropriate Usage
The procedure performed is related to the original procedure or a staged procedure.
If the services performed are related to the original procedure, it is considered part of the global period.
 

thomas7331

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thomas7331,
When the provider did a left side radiofrequency ablation and previously in the week did right side procedure, I think it could believed that the other side was planned at the time of the original procedure but some reason they had to stage the other side. For modifier 79, you would have to be under the impression that the other side was not staged based on the original procedure that was performed. The fact they repeated the same procedure a week later would make one think they had the second procedure planned at the time of the original.

In the types of charts I've coded, staged procedures have usually been related procedures at the same anatomical location and problem and not procedures that are directed at a different site or different pathology. I agree, certainly, if the documentation supported that this second procedure was staged, it would support the use of modifier 58 for this. But as this information was not indicated in the original post, I don't think it can be assumed, and codes or modifiers can't be assigned based on what one believes or thinks, but only on what is stated in documentation. Either way, though, both modifiers accomplish the same purpose and substituting one for the other would not cause a payment error and the difference between the two is more of a technicality.
 
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