For those of you that follow my "coding life" .. I had a very successful teaching and training session in Scottsdale, AZ for the AzHIMA.
I did a educational session on Modifiers, Myths & Misconceptions, and another on the DaVinci robotic device, and many of the new and emerging surgical technology uses for the robotic assist device. Over the next few weeks, I'll be including information from my presentation into the blog but for today...
This is a copy of the column that I have written for Dr. Rob Olsen in conjunction with the site: http://obgynhospitalist.com These three modifiers, 58, 79 and 79 can be very confusing for coders, and it is imperative that you understand the differences between them. Since my background is primarily in OB, the coding scenarios are relevant to that specialty. However, the information remains pertinent to all CPT guidelines and specialties. Enjoy! L : )
Modifiers 58, 78, 79 – OB Hospitalist coding help!
Modifiers 58, 78 and 79 are confusing for coders and providers alike. Even experienced coders have a difficult time determining which of these modifiers should be appended. The CPT modifiers -58, -78 and -79 are very similar in definition, yet are very different in scope and usage. CMS and many 3rd party insurance carriers have specific guidelines and edits as to which CPT codes these modifiers can be used with. In some OB hospitalist practices, you have the luxury to have a coder assigned to your practice to help with these difficult issues for coding your services. If you do not have a coder on-staff, or easily accessible, this should help you out. Feel free to share this with your coders, billers, or practice managers.
The definitions outlined within CPT for these three modifiers contain “critical verbiage” that you need to understand to help get your claims paid timely and correctly. The key to getting claims paid with these modifiers is to ensure you’re using the correct modifier on the correct procedure within the specified guidelines for surgical procedure/services.
All three of these modifiers have similar definitions, and also include the words ‘related procedure’ and ‘during the post-operative period” within their definitions. Therefore, a good understanding of each of these will help you get the correct modifier appended, in the correct situation and speed your claim though the adjudication process to payment from the insurance carrier.
The other issue at hand for these 3 modifiers is that they “re-set or re-start” the global service days for the service or procedure (eg a new postoperative period begins when the next service or procedure in the series is billed). The Medicare Fee Schedule Database (MFSDB) global surgery indicator identifies CPT procedures as 000, 010, 090, YYY, or ZZZ global surgery days
§ Definition: Modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
It may be necessary to indicate that the performance of a procedure or service during the postoperative period was
a) planned or anticipated (staged);
b) more extensive than the original procedure; or
c) for therapy following a surgical procedure.
This circumstance may be reported by adding modifier -58 to the staged or related procedure. Note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier -78.
There are a number of critical verbiage areas within the definition for modifier 58. The first is the notation of “staged” OR “related procedure or service” A ‘staged’ procedure is one that is pre-planned to take more than one session in the operating room or procedure room. Normally “staged” procedures are performed in two or more separate sessions with a designated time period between the operative/procedure sessions to facilitate healing, or to lower the medical risk to the patient. (eg (A tubal ligation scheduled 30 days post vaginal delivery)
o Definition: Modifier 78 Unplanned return to the operating/procedure room by the same physician or Other Qualified Health Care Professional following initial procedure for a related procedure during the postoperative period
Note: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and require the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76)
Modifier 78 also contains verbiage that was updated to reflect an unplanned return to the operating room/procedure room.... This change in the description of Modifier 78 allows for a provider to now provide ‘unplanned’ services in either an operating room or a procedure room. A procedure room, can be one that is located in a physician office, ambulatory setting or a formal operating room setting.
Another key clue to usage of this modifier is the word “unplanned’. This is extremely important that the procedure or surgery was unplanned in relationship to the original procedure or service.
Example: Mary White has an uneventful vaginal delivery(59400) , Four days post discharge, Mary was returned to the procedure/operating room, for a post-operative hemorrhage. , Dr. Sam then performed a postpartum D&C for the uterine hemorrhage. In this scenario, the modifier 78 would be appended to CPT code 59160 .
As of 2013, the definition of modifier 78 now reflects updated verbiage to include both physicians, and qualified health care professionals. This verbiage change has also been included in many of the 2013 CPT codes for evaluation and management services and procedural and surgical services.
Modifier 78, like modifier 58, also re-sets/re-starts the global service days in relationship to the Medicare Fee Schedule Database (MFSDB). . If the surgery or procedure does not have these specific indicators, it is inappropriate to use modifier 78 with those codes.
An example of an inappropriate CPT code to add a modifier 78 to, is code 59409 Vaginal Delivery only. The MFSDB denotes the global service days for code 59409 as MMM. Many maternity services have an MMM designation. If you are unsure about the MFSDB designation, or postoperative days associated with your surgical code, you can obtain this information from the CCI indicators on the Medicare website at www.cms.hhs.gov.
Another important issue for the usage of modifier 78 is that the unplanned surgery/procedure be performed by the same physician who performed the original procedure.
Inappropriate usage of modifier 78, is appending this modifier to a procedure/surgery that is unrelated to the original procedure, or if a different physician performed a subsequent unplanned return to the operating room/procedure room.
o Definition: Modifier 79: Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
Note: The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier -79. (for repeat procedure on the same day, see modifier -76)
Usage of modifier 79 requires the service/procedure to be an “unrelated” procedure or service performed by the same physician within a post-operative time frame. You will note that the critical verbiage between modifier 78 and modifier 79 is that modifier 78 is the modifier for a “related” procedure; modifier 79 is for an ‘unrelated” procedure. We also have to tie this back to modifier 58, which denotes a “staged or related” procedure.
The definition verbiage for modifier 79 does not have a requirement that the service/procedure be performed in an operating room or a procedure room (as is with modifier 78). The definition of modifier 79 does require this to be appended if the same physician performs an unrelated procedure within a postoperative time frame. An example of the appropriate use of a modifier 79 is:
Example: Dr. Sam a cesarean section delivery code 59510 on patient Dana Mann. One week later, Dr. Sam then performs a skin tag removal from Dana’s back in the hospital outpatient surgery center. (CPT code 11200 with a 10 day global surgery indicator). When the claim is submitted modifier 79 should be appended to code 11200 to denote this is an unrelated procedure to the previous cesarean procedure, code 59510.
Modifier 79 rules:
· Modifier 79 applies to surgical procedures performed on patients while they are in a postoperative period for a different, unrelated surgery.
o eg, the new surgical procedure is performed to treat a new problem or injury.
· The unrelated procedure starts a new global period.
· Do not report modifier 79 with modifiers 58 or 78. It is inappropriate if the procedure performed is staged or related to the original procedure, which are included in the definitions for mods -58 and 78.
· Modifier 79 is an information only modifier, and does not affect reimbursement from insurance payers.
As confusing as these three modifiers are, CPT has very specific verbiage that outlines exactly the circumstances for when they should be used. As a coder or biller, take the time to read carefully the operative scenario, and if in doubt regarding the procedures, be sure to query the physician or provider to clarify all necessary information.
If you are receiving denials from the insurance carrier or 3rd party payer, in regard to an incorrect or inappropriate modifier on your claim, take the time to re-review the operative/procedure note and the modifier definitions. Many times, it is a quick fix to correct the modifier and re-submit your claim for payment. As a coder, understanding the ‘critical verbiage’ contained in the definitions of modifiers 58, 78 and 79 will enhance not only your coding expertise, but also expedite a clean claim and improved reimbursement back to the medical practice.