3 Common (But Misunderstood) Post-surgical Modifiers
There are several surgical modifiers but there are three in particular that are the most misunderstood among billers. Modifiers 58, 78, and 79 are used to define surgical procedures during global days with some variations. We have explained these nuances below:
Staged or Related Procedure or Service by the Same Provider During the Postoperative Period
Modifier 58 can be used when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was:
- planned or “staged” or
- more extensive than the original procedure; or
- for therapy following a surgical procedure; or
- for the reapplication of the cast within the 90-day global period.
An example of when to use modifier 58 would be if a patient had a removal of a breast lesion (CPT 19120) followed in less than 90 days by the removal of the entire breast (CPT 19307). Bill CPT 19307-58 for the second procedure. Another postoperative period begins when the second procedure in the series is billed.
Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period
Modifier 78 is used for an unplanned return trip to the operating room for a related surgical procedure during the postoperative period of the initial major surgery. The allowance will be reduced, since pre- and postoperative care is included in the allowance for the prior surgical procedure.
An “operating room” is defined as a place of service specifically equipped and staffed for the sole purpose of performing surgical procedures. The term included a cardiac catherization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.
Unrelated Procedure or Service by the Same Provider During the Postoperative Period
Modifier 79 is used for unrelated procedures by the same provider (or provider of the same specialty in the same surgical group) during the postoperative period. Unrelated procedures are usually reported using a different ICD-9-CM diagnosis code. Another postoperative period begins when the second procedure in the series is billed.
Note: The use of RT and LT modifiers is helpful, and should be billed as the second modifier following modifier 79, but not in place of it.
The guidance that Medicare carriers use to deny is described in “The Medicare Claims Processing Manual” which states:
“Do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier “-58,” “-78” or “-79.” These services should be denied.” (CMS Publication 100-04, Chapter 12, Section 40.4A)