Correct Use of Modifiers 58, 78 and 79 to Report Post-operative Procedures

Patient visit documentation covering the procedures/services provided must be done accurately taking into account the many variables that may have an impact on reimbursement. One of these significant variables is the global period. A global period is the time before, during and after a surgical procedure that covers the patient care provided for that particular procedure. If the provider performs a new service/procedure on a patient who is within the global period of an earlier procedure, the new procedure/service must be signified clearly using a modifier, i.e., a 2 character code used to indicate that a service/procedure has been altered by some specific circumstance, but there is no change in its code or definition.

Modifier Types– Payment and Information Modifiers

• Payment modifiers have a direct impact on the reimbursement rate
• Information modifiers indicate important documentation details, as for example, the surgical site
• Payment modifiers must be listed in the first modifier position before any information modifiers

CPT Surgical Package

To clearly understand global modifiers, it is necessary to understand the global surgical package as defined by CPT. By this definition, there are fundamental services included in every procedure that should not be reported or billed separately. These services are typically provided during the pre-operative period, the actual surgical procedure, and during the post-operative period.

CPT ® Surgical Package Definition

In addition to the surgical procedure, these services are included:

Preoperative

• Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
• Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)

Postoperative

• Immediate postoperative care, including dictating operative notes and talking with the family and other physicians
• Writing orders
• Evaluating the patient in the post-anesthesia recovery area
• Typical postoperative follow-up care

Source: Adapted CPT® 2013, American Medical Association

Post-Operative Modifiers 58, 78 and 79

Modifiers 58, 78 and 79 are to be appended when the same surgeon performs services within the surgical package that do not fall within the purview of normal post-operative care. These modifiers were introduced specifically to report the various post-operative events that may occur. Providers need to keep in mind that inappropriate use of these modifiers very often lead to claim denials or reviews, and therefore have to be applied accurately to minimize denials and increase reimbursement.

Use of Modifier 58

A staged or related service/procedure by the same physician or any other qualified healthcare professional during the post-operative period is to be reported using Modifier 58. It signifies the following aspects:

• The procedure was planned at the time of the original procedure, or staged
• The procedure was “more extensive” than the original procedure, or
• The procedure was provided as therapy following a diagnostic surgical procedure

Important

• Do not append modifier 58 when the CPT code used clearly indicates “one or more sessions” or “one or more visits,” if the following sessions are performed during the post-operative period of the initial session
• Modifier 58 can be used with these types of procedures only if a subsequent session is performed outside the post-operative period of the original procedure
• The planned surgical procedure begins a new global period
• Do not use modifier 58 with modifiers 78 or 79
• Modifier 58 is an information modifier

Modifier 78 – Correct Usage

Technically, modifier 78 reports “an unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period.” It signifies an unexpected outcome of the previous surgery such as post-surgery hemorrhage, infection or debridement.

Note:

• The unexpected surgery/procedure does not reset or begin a new global period
• Modifier 78 is a payment modifier and the payment for procedures reported using this modifier will be 70 or 80 percent of the physician fee schedule for the surgical procedure
• The unplanned procedure is not part of the original surgery, but involves a separate operative session
• Do not use modifier 78 to report the same procedure repeated during the same operative session
• Do not use modifier 78 along with the modifiers 58 or 79
• When using modifier 78 with assistant surgeon modifiers 80, 81, 82 and AS, list the assistant surgeon modifier first

Accurate Use of Modifier 79

Modifier 79 is to be appended to the surgery codes when you want to report an unrelated procedure/service by the same surgeon or other qualified healthcare professional during the post-surgery period. The unrelated procedure may be associated with a different diagnosis / for the treatment of a new problem or injury.

• Modifier 79 is required to report identical procedures that are provided on the same day, but are not repeats of the same procedure on the same body site
• A new global period begins with the second procedure, and the procedure will be reimbursed at 100% of the amount allowed by the payer
• Modifier 79 should not be used along with modifiers 58 or 78
• Modifier 79 is an information modifier

Do Not Use the Modifiers 58, 78 and 79 to Report the Following

Modifiers 58, 78 and 79 should not be used to report routine post-operative care during the post surgery period.

• Critical care for burned/seriously injured patients
• Services provided for complications after a procedure that does not involve the patient returning to the operating room
• Pain management services associated with the surgical procedure
• Follow-up evaluation and management visits during the patient’s recovery period
• Dressing changes
• Removal of staples, sutures, wires, tubes, lines, catheters, drains, splints and casts
• Local incisional care