• Surgical Complications, Part One: When to Use Modifiers –58, –78, and –79

    By Sue Vicchrilli, COT, OCS, Academy Coding Executive, and John M. Haley, MD, Member of the Academy Health Policy Committee

    This article is from July/August 2011 and may contain outdated material.

    Despite surgeons’ best efforts, patients will occasionally experience a complication that requires additional surgical intervention. When that happens, can you bill for the initial procedure and also bill separately for the later intervention? It depends. Under the concept of the “global surgical package,” your first bill doesn’t just cover payment for the original procedure, it also covers certain other services that the physician is expected to furnish during the “global period.” If the later intervention falls within the global surgical package of the initial procedure, then you can submit the second bill only in circumstances where modifier –58, –78, or –79 applies.

    How long is the global period? Under Medicare, the global period includes a postoperative period for “minor surgeries” that is either 0 days or 10 days after the day of surgery; for “major surgeries” it is 90 days.

    What services are covered during the global period? Services include:

    • preoperative visits beginning the day prior to surgery (for a major surgery) and the day of surgery (for a minor surgery), unless it is the exam to determine the need for a major surgery (in which case modifier –57 would be appended to the exam code),
    • intraoperative services that are typically a necessary and usual part of the surgical procedure,
    • complications following surgery unless it is necessary to return to the operating room or the dedicated office-based procedure room,
    • postoperative visits during the duration of the postoperative period,
    • supplies,
    • related visits in the hospital,
    • related visits in an ASC, and
    • related visits for critical care services.

    When to Use –58, –78, and –79

    Modifier –58 Staged or related procedure or service by the same physician during the postoperative period.You can use this when the later intervention was: 1) more extensive than the original procedure, 2) planned and documented prospectively at the time of the original procedure, or 3) an injection given in the lane. It doesn’t apply to laser codes that include “per session” or “one or more sessions” as part of their CPT descriptor. Payment is 100 percent of the allowable, and a new global period begins.

    Example: A patient presents during the postop period of a trabeculectomy in the right eye and receives a therapeutic injection of 5-FU. Use CPT code 68200–58–RT for the subconjunctival injection and J9190 for the fluorouracil.

    Modifier –78 Unplanned return to the operating/procedure room by the same physician or other qualified health professional following initial procedure for a related procedure during the postoperative period. This definition changed in 2009, when the words “unplanned” and “procedure room” were added. Now, instead of returning to the OR or ASC, you can receive payment for surgeries performed in your office’s dedicated procedure room.

    Payment for surgical codes is divided into three parts, with the pre-, intra- and postoperative components being allocated 10, 70 and 20 percent of the allowable, respectively. When modifier –78 is appended, payment is made at 80 percent of the allowable. Since this payment doesn’t include the postoperative component’s 20 percent, a new postop period doesn’t begin—the global period of the original surgery is the only one in effect.

    Example: A YAG laser capsulotomy is performed in the right eye during the global period of cataract surgery in the same eye. Use code 66821–78–RT.

    Modifier –79 Unrelated procedure or service by the same physician during the postoperative period. The procedure could be unrelated because it is performed in the other eye. Or it could be a new problem, not related to the initial surgery of the same eye. Payment is 100 percent of the allowable, and a new global period begins.

    Example: A corneal foreign body is removed from the left eye during the global period of a functional blepharoplasty on the right upper lid. Use CPT code 65222–79–LT.