28 Jan 2016

MODIFIER 58, 78 and 79

Modifiers 58, 78 and 79 are used only with the surgery codes in postoperative global period.

(Global period is the time before, during, and after a surgical procedure that covers the patient care for that particular surgical procedure. When a physician performs a new surgery procedure for a patient who is within the global period of a previous surgery procedure, the new surgery procedure must be distinguished by using a modifier)

The global period for the minor and major surgeries,

         1.     Minor surgeries - Either 0 days or 10 days after the day of surgery

         2.     Major surgeries - 90 days

Modifiers 58, 78, and 79 are mutually exclusive to one another, only one of these modifiers would be used with the surgery procedure performed within a postoperative global period.

The use of modifiers requires precise perceptive of the purpose of each modifier.       

Now we are going to see some of the global period modifiers and how it would alters the reimbursement.

Modifier 58

The modifier 58 - Staged or related procedure or service by the same physician during the post-operative period.

It’s necessary to indicate that the performance of a surgery procedure during the post-operative period was
     a)  Planned or staged,
     b)  Must be more extensive procedure than the original procedure performed earlier,
     c) For therapy following a surgical procedure.

For the above circumstances would be reported by adding modifier 58.

It’s not obligatory that the physician has to mention planned stages in order for a procedure to qualify for the modifier 58.

The subsequent surgery procedure can be within a stated plan of care, and more extensive procedure because the original procedure did not achieve the preferred outcome as planned.

Note: Do not append modifier 58 to procedures whose definitions include the description “one or more sessions” (Eg, CPT 67105 - Repair of Retinal detachment, 1 or more sessions, Photocoagulation, with or without drainage of sub retinal fluid) if the subsequent sessions are performed during the postoperative period of the initial session.

Modifier 78

Modifier 78 – Unplanned return to the operating room by the same physician following the initial procedure for a related procedure during the postoperative period

Modifier 78 is used to indicate the performance of a surgery procedure during the postoperative period or on the same the treat the complication of original procedure, which required return to the operating room following initial surgery with 10 or 90 days global period.

When the new surgery code used to describe a service for treatment of complications is the same as the surgery code used in the original procedure still it’s must to append modifier 78 with the subsequent procedure.

Basically payment for surgical codes is divided into three parts, (pre-, intra- and post op) which is 10, 70 and 20 percent of the allowable, respectively. When modifier –78 is used, payment is made at 80 percent of the allowable.

Since this payment doesn’t include the postoperative component’s 20 percent, a new post op period doesn’t begin. Modifier 78 reimbursement is intra-operative percentage only.

Note: Do not append modifier 78 to assistant surgeon.

Modifier 78 is not used to report a repeat of the same surgery during the same operative session.

Modifier 79

Modifier 79 - Unrelated procedure by the same physician following initial procedure during the postoperative period.

Modifier 79 appended to surgical procedures performed on patients during the postoperative period for a different/unrelated surgery. The new surgical procedure is performed to treat a new problem during global period.

Note: Modifier 79 does not always require a different diagnosis or a different surgery procedure. The same procedure being performed on bilateral body parts in different operative sessions, the subsequent surgery falls within the global period of previously performed surgery then also we can append modifier 79.

Modifiers 78 and 79 should not be used to when multiple surgeries performed during the same operative session.

How to determine whether a subsequent procedure is related, staged, or unrelated to the original surgery,

The reason for the original surgery and the reason for the subsequent procedure during the global postoperative period must be considered.
            1.     Services treating complications from the original surgery are always related.
            2.     Procedures to treat or assist with expected developments in the healing process are always related.
            3.     Procedures to treat the same or similar problems in the contra-lateral, non-operative organ, extremity, or joint are unrelated.

Don’t append modifier 78 when the procedure is performed at the place of service 11 (Office)