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Thread: Modifier 79

  1. #1
    Join Date
    Apr 2007

    Question Modifier 79

    AAPC: Back to School
    In the MArch 16th Part B News there is caution using modifier 79 for any surgical procedure. It also says this modifier is for procedures with 90 day global and to use only if you return to the OR. Where would 20610 fit in?? This is an injection with no global so if we do a 90 day procedure such as 29881 for a tear and during the post-op a new problem unrelated to the surgery arises such as DJD and we do the injection, this modifier would be used only because the dx is unrelated. There isn't anything else to use. I would think this would be okay if the DJD wasn't diagnosed prior to surgery??

    Any thoughts......Thanks!

  2. #2
    Join Date
    Apr 2007


    Unless its a totally different body part, you would not be able to bill 20610 after a knee scope regardless of the diagnosis, for MEDICARE patients only. This is a Medicare guideline, thus the warning regarding the overuse of the 79 modifier.

    Hope this helps
    Mary, CPC,COSC

  3. #3
    Join Date
    Apr 2007

    Smile Modifier 79

    Please tell me what Medicare guideline prevents us from billing the 20610 post-op?? We bill occasionally for effusion and use mod 58 or if totally unrelated would use mod 79 and we are paid, no audits yet...please clarify.



  4. #4
    Join Date
    Apr 2007


    Ouch..I'll pray that RAC avoids you!!! Here is the Medicare policy:

    Medicare B News Issue 180 Mar 2000
    Publish Date March 2000
    States Affected AK,AZ,CO,HI,IA,NV,ND,OR,SD,WA,WY
    Subject MODIFIER 24 - Appropriate Use
    "Medicare reimburses surgical procedures under a Global Fee Methodology. According to HCFA guidelines, payment is allocated on a percentage basis for preoperative, intraoperative and postoperative care.

    Based on a complex medical review of claims during October through December, 1999, this carrier has identified that some providers incorrectly use MODIFIER 24, which indicates an unrelated E/M service by the same physician during the postoperative period.

    Postoperative care includes all related E/M services rendered from the day of the surgery through the end of the indicated global period, as established in the Medicare Physician Fee Schedule. Any routine followup, consisting of an office visit, a surgical procedure performed in the office due to postoperative complications, or admission and follow up E/M in the hospital, should not be billed as a separate service. These services are considered to be included in and part of the global service period of the surgical procedure.

    Status post knee surgery: The patient returns with increased pain and swelling. Physician performs an ARTHROCENtesis. Both the E/M visit and procedure code 20610 are included in the postoperative fee.

    Patient is status post mastectomy: The patient returns to the office after a fall at home, with bruises on arms and legs. An E/M service with a MODIFIER 24 is justified as a separate, non-surgery-related visit."

    100-04 Claims Processing Manual Section 040
    Chapter 12-Physician Billing
    Subject Physicians/Nonphysicians Practitioners - Section 40 - Surgeons and Global Surgery
    "Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;

    · Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;

    · Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;

    · Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;

    · Postsurgical Pain Management - By the surgeon;

    · Supplies - Except for those identified as exclusions; and

    · Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes."

    "Some services are integral to large numbers of procedures. Other services are integral to a more limited number of procedures. Examples of services integral to a large number of procedures include:

    - Cleansing, shaving and prepping of skin

    - Draping and positioning of patient; positioning of patient

    - Insertion of intravenous access for medication administration

    - Sedative administration by the physician performing

    a procedure (see Chapter II, Anesthesia section)

    - Local, topical or regional anesthesia administered by the physician performing the procedure

    - Surgical approach, including identification of anatomical landmarks, incision, evaluation of the surgical field, simple debridement of traumatized tissue, lysis of simple adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring

    - Surgical cultures

    - Wound irrigation

    - Insertion and removal of drains, suction devices, and pumps into same site

    - Surgical closure and dressings

    - Application, management, and removal of postoperative dressings including analgesic devices (peri-incisional TENS unit, institution of Patient Controlled Analgesia)

    - Preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, transcription as necessary to document the services provided

    - Surgical supplies, except for specific situations where CMS policy permits separate payment

    In the case of individual services, there are numerous specific services that may typically be involved in order to accomplish a column one procedure. Generally, performance of these services represents the standard of practice for a more comprehensive procedure and the services are therefore to be included in that service.

    Because many of these services are unique to individual CPT coding sections, the rationale for correct coding will be described in that particular section. The principle of the policy to include these services into the column one procedure remains the same as the principle applied to the generic service list noted above. Specifically, these principles include:

    1. The service represents the standard of care in accomplishing the overall procedure.

    2. The service is necessary to successfully accomplish the column one procedure; failure to perform the service may compromise the success of the procedure.

    3. The service does not represent a separately identifiable procedure unrelated to the column one procedure planned."

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