Physicians and billers are often confused regarding which modifiers to use when a procedure is performed in the global period of a prior procedure. Here’s my attempt to provide some clarity.
Q. What modifiers apply when a surgical procedure occurs during a global surgical period?
A. Three modifiers in particular affect a surgical retina practice’s proper coding and reimbursement within the global period of another surgical procedure. The Current Procedural Terminology (CPT) manual describes the 3 modifiers we are going to review:
- 58: Staged or related procedure or service by the same physician or other qualified health-care professional during the postoperative period.
- 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.
- 79: Unrelated procedure or service by the same physician or other qualified health-care professional during the postoperative period.
Q. How is modifier 58 used?
A. Misunderstanding is common when deciding how and when to use modifier 58. According to the Medicare Claims Processing Manual (MCPM), modifier 58 was established to facilitate billing of staged or related surgical procedures performed during the postoperative period of the first procedure. Three scenarios described by the MCPM apply for using modifier 58 for a procedure or service during the postoperative period: that the procedure was planned prospectively or at the time of the original procedure; that the procedure was more extensive than the original procedure; or that the procedure was for therapy following a diagnostic surgical procedure. A new postoperative period begins when the next procedure in the series is billed.1
The first 2 scenarios are most common. The first illustrates a “staged” scenario. A staged procedure, which follows another procedure, is preplanned when the decision for the primary procedure was made. In other words, the surgeon anticipates needing the second procedure prior to performing the first. The second scenario, “more extensive,” does not require preplanning. From the payers’ perspective, more extensive is defined as having greater reimbursement.
An example of a staged procedure is a vitrectomy ILM peel for DME (CPT 67042) followed by a sequence of preplanned intravitreal injections (CPT 67028) of anti-VEGF to treat the DME in the same eye. It is obvious that this does not represent more extensive in terms of value, but the injections are clearly preplanned. If the injections were not preplanned, the payer would likely view the subsequent injections as postoperative care, reimbursing only the drug.
More extensive is easier to understand but often missed. A classic scenario is a retinal detachment repair (CPT 67108) followed by a complex retinal detachment repair involving proliferative vitreoretinopathy and membrane peeling (CPT 67113) in the same eye. In this case, the second retinal detachment repair was not preplanned, but it was more extensive and has a higher reimbursement. We often see practices erroneously code this scenario with modifier 78. Another example is when the tear progresses to a retinal detachment, requiring vitrectomy retinal detachment repair (CPT 67108). In this case, more extensive also applies.
Modifier 58 reimburses the surgeon based on 100% of the allowed amount and restarts the global period (as long as it exceeds the first global period). In the first scenario — the injection following the vitrectomy — the global period would continue running from the vitrectomy because CPT 67028 has 0 global days, but in the second scenario a new 90-day clock commences.
Q. What is appropriate use of modifier 78?
A. According to the MCPM, “When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier ‘-78’ to the related procedure.”2 Medicare and other third-party payers do not typically pay for treatment of complications during a global period. However, when treating the complication requires a return to the operating room, the related care is covered. For example, a patient underwent a vitrectomy retinal detachment repair (CPT 67108) and unexpectedly develops endophthalmitis within the first week. The surgeon returns to the operating room to perform a vitrectomy (CPT 67036). The second vitrectomy is treating a related and/or complication of the first procedure. The second vitrectomy is not more extensive or staged; therefore, modifier 78 applies. Modifier 78 reimburses the surgeon approximately (depending on the payer) 80% of the allowed amount, but it does not restart the global period. The global period continues to run from the first procedure.
Q. How about modifier 79?
A. Of the 3 modifiers, 79 is the easiest to use and simplest to understand. The MCPM describes modifier 79 as follows: “Report an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.”3
The classic illustration is a procedure on the fellow eye during the global period of a procedure on the primary eye. For example, a patient with diabetic retinopathy and DME needs a focal laser in both eyes. The right eye is treated and coded as CPT 67210, and 10 days later focal laser is applied to the left eye (also CPT 67210). Modifier 79 appended to the second treatment facilitates payment of an unrelated service. Modifier 79 reimburses the surgeon based on 100% of the allowed amount and starts its own global period. The 2 global periods run concurrently. RP
- CMS Medicare Claims Processing Manual (MCPM) Chapter 12§40.2 (A)(6). Staged or related procedures. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed September 11, 2019.
- CMS Medicare Claims Processing Manual (MCPM) Chapter 12§40.2 (A)(5). Return trips to the operating room during the postoperative period. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed September 11, 2019.
- CMS Medicare Claims Processing Manual (MCPM) Chapter 12§40.2 (A)(7). Unrelated procedures of visits during the postoperative period. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed September 11, 2019.