shoulder surgery during global

jpenland1

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Hey! Happy Thursday! i have a question for all of you shoulder specialists please. patient had a rt shoulder surgery 9/5/08, she was in an accident and reinjured the rt shoulder, so she had the same surgery 12/1/08 86 days after the first one. would this be a 78 or 79 mod? i am thinking 78, but its also unrelated to the first one. HELP!
Thanks in advance
Jen P:eek:
 

mbort

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Hey! Happy Thursday! i have a question for all of you shoulder specialists please. patient had a rt shoulder surgery 9/5/08, she was in an accident and reinjured the rt shoulder, so she had the same surgery 12/1/08 86 days after the first one. would this be a 78 or 79 mod? i am thinking 78, but its also unrelated to the first one. HELP!
Thanks in advance
Jen P:eek:

if its the exact same procedure code, you should probably use the 76 1st and then the 79
 

mbort

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the 78 is utilized for "complications" of the 1st surgery, since this was a re-injury (even though its related--technically its not) the 79 would apply rather than the 78. Make SURE that the doctor has clearly dictated that this is a new injury to the old body part.

and yes the 79 would need to go on all line items. (76 only on the procedure that is exactly the same code as previous).
 

jpenland1

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Thank you so much! I am not sure what i would do without these list serves to ask questions. when you are the only "coder" in the office, its hard to find out certain answers. I do apreciate you taking your time to help me.

Jen P
 

jpenland1

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So, you said to make SURE that it was in the documentation. it is in the office notes but not in the OP note. should i tell the doc to do an addendum to the OP note? or will the office note before the surgery suffice?
 

mbort

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it would be nice to have it in the op note, but as long as you have the "proof" if needed for any appeal purpose that is okay (only because its history of injury that were talking about).
 
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