Post-surgery modifiers primer
Properly using modifiers 58, 78, and 79 ensures accurate reimbursements.
BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA
Surgical CPT modifiers, which apply to claims within a global period after an initial surgery on a patient, are commonly used but often misunderstood. Failure to use them properly and in the correct circumstances can result in lower reimbursement than your office should otherwise be entitled. As a result, it’s important to use them properly.
Here, I describe some appropriate scenarios for these confusing post-surgery modifiers.
This modifier is the easiest to understand. It is mostly commonly used when the global (post-operative) period is still running on an eye but we need to tell the payer that a second operation is not related in any way to the first one. Most often, the second operation is on the other eye.
For example, if a patient has cataract surgery with an IOL in the right eye (66984-RT), the global period is 90 days, so any other surgery done on this patient’s eyes in the next 90 days needs a modifier. If cataract surgery with an IOL is done on the left eye three weeks later, the claim must reflect that it is not related to the right eye surgery — using “LT” alone is not sufficient for the payer. A claim for the left eye should be filed as 66984-79LT. Note that modifier 79 (a payment modifier) comes before LT, a location modifier.
Using modifier 79 allows the second eye to be paid in full. Remember: Each eye’s global period runs independent of the other.
CPT notes that use of this modifier is appropriate when “… 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.”
Post-surgical Modifier CPT Descriptions*
• Modifier 58. Staged or related procedure or service by the same physician or other qualified healthcare professional during the post-operative period.
• Modifier 78. 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 post-operative period.
• Modifier 79. Unrelated procedure or service by the same physician or other qualified healthcare professional during the post-operative period.
*Keep in mind: if no global period is in effect, these modifiers are not needed.
There are two issues to pay special attention to within the citation above; the first is “staged” and the second is “more extensive.” If a second eye operation is related but fits (a) or (b), use modifier 58. Reimbursement is 100% for the second procedure, but a new global period begins. Examples of each of these are as follows:
• Staged (a). A second procedure is definitively planned before the first procedure takes place, is medically indicated, and is noted in the medical chart before the first procedure. Even if the second procedure value is smaller, it was planned (staged) in advance — and will be paid at 100% if modifier 58 is added to the second procedure. The global period begins again, but if shorter than the first procedure’s, it may expire before the larger, more extensive surgery’s global period. You are not required to use modifier 78 here and accept a decreased payment (discussed below) if modifier 58 applies.
• More extensive (b). In this case, a second procedure is done inside the global period but it is more extensive; from the payer’s perspective, it has higher value (more reimbursement). For example, a lesion is removed from the right lower lid and sent to pathology (CPT code 67840 is used, which has a 10-day post-op global period). If pathology reports show a tumor that needs prompt attention, and your surgeon performs a more extensive (and generally higher reimbursed) surgery within 10 days, the second procedure needs modifier 58 and a location code (such as RT/LT, or E1-E4, as appropriate). Filing modifier 58 means you would receive 100% payment for the second surgery, even though a global period for this lid is already in effect; a new global period (10 or 90 days) begins. Because of this, post-op visits are not billable (unless completely unrelated) until the “new” global period from the more extensive surgery expires.
This modifier is used when you need 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 requires the use of the operating room/procedure room, it may be reported…” Using this modifier tells the payer:
• The second procedure is related to a prior operation; a global period is still in effect.
• The second procedure was done in a special room that meets the criteria of “operating room” (eye exam lanes do not qualify).
• Payment is only for the surgical work portion (not the post-op), so that means about a 20% reduction depending on the payer and procedure.
• A new global period does not begin.
For example, although YAG laser capsulotomy, OD 10 weeks after cataract surgery/IOL, OD is unusual, it is occasionally medically necessary and appropriate care. If the first operation was 66982-RT, the second is 66821-78RT. Payment is about 20% less than your usual 66821-RT, but the global period for this right eye expires at the same time as the cataract global period, not 90 days after the YAG. That means a visit 98 days after the initial cataract surgery would generally be billable even though this date is only a few weeks into the YAG’s “normal” (90 day) post-operative period.
You must know how to correctly use these three surgical modifiers. Failure to do so results has significant reimbursement ramifications. In one case, you might “give away” office visits; in another you might give away reimbursed “post-op” care.
As always, “Good Coding” to you! OP
Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.