These pearls and sample scenarios will enhance your knowledge.
This article highlights appropriate use of modifiers -58, -78, and -79.
Modifier -58 Staged or related procedure or service by the same physician during the postoperative period
• Related, may or may not be preplanned
• Was more extensive than the original procedure
• Was a therapeutic procedure performed after a diagnostic procedure
• Was planned and documented prospectively at the time of the original procedure
• Does not apply to laser codes 67141, 67145, 67208, 67210, 67218, 67220, 67229
• Payment is 100% of the allowable, and a new global period begins
Modifier -78 Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period
The definition changed in 2009 to include the words unplanned and procedure room—ie, in the office setting
• Related and unplanned
• Payment is 80% of the allowable; do not begin a new global period
• A different diagnosis from the surgical diagnosis does not mean the new surgery is unrelated
Modifier -79 Unrelated procedure or service by the same physician during the postoperative period
Applies to any unrelated surgical procedure, minor or major, performed within the global surgical period
• Payment is 100% of the allowable
Modifiers can financially make or break a practice. Misuse of modifiers is listed by payers as one of the top five reasons for claim denial; often no modifier is appended when one is needed, or the wrong modifier is chosen. Modifiers are often confusing, especially surgical modifiers. Test your modifier mastery by determining the correct claim submissions for the case studies below. Will it be modifier -58, -78, or -79? Answers are listed at the end of the article.
ARE YOU A MODIFIER MASTER?
Case Study No. 1
A patient presents during the postoperative period of a vitrectomy in the left eye (OS). Examination reveals the need for an intravitreal injection, which is then performed.
Case Study No. 2
A patient undergoes complex repair of a retinal detachment (RD) (CPT code 67113 -RT). She returns to the OR 6 weeks later for additional surgery for recurrent RD in the same eye secondary to proliferative vitreoretinopathy in association with a giant tear.
Case Study No. 3
Panretinal photocoagulation is performed on a patient’s right eye (OD). The same treatment is performed 1 week later OS.
Case Study No. 4
A patient’s RD OD is repaired using photocoagulation (CPT code 67105). During the 10-day postoperative period, 67107 Repair of retinal detachment; scleral buckling is performed on the same eye.
Case Study No. 5
A patient undergoes pneumatic retinopexy OD with possible laser or cryo 3 days later. (First surgery 67110 -RT.)
Case Study No. 6
An anterior chamber tap OS is performed on a patient during the global period of CPT code 67036 PPV to remove a vitreous hemorrhage.
Case Study No. 7
CPT code 67108 Repair of RD with vitrectomy is performed OS within the global period of CPT code 67110 Repair of RD pneumatic retinopexy. What modifier(s) should be appended to 67108?
Case Study No. 8
The surgeon performed CPT code 67145 Prophylaxis of RD (eg, retinal break, lattice degeneration) without drainage, one or more sessions; photocoagulation due to a tear OS. During the postoperative period, the patient returned with a new unrelated tear requiring surgery. Can a second laser session in the same eye be billed for?
MORE MODIFIER MASTERY
Following are a few additional pointers regarding modifiers -51, -53, and -GA to further boost your modifier chops.
Modifier -51 Multiple procedures is rarely required by payers. Systems are sophisticated enough to recognize multiple procedures performed during the same surgical session.
Modifier -53 Discontinued procedure or service. When a surgery is discontinued for any reason, payers will require an operative report to determine how much of the surgery has been completed in order to determine proper payment. There is no global period on discontinued surgeries.
Modifier -GA indicates to Medicare Part B that an Advance Beneficiary Notice is on file. The Advance Beneficiary Notice is appropriate to use when it is not clear, either by frequency or by diagnosis, that the test, injection, or surgery is covered. Modifier -GA should not be appended to all intravitreal injection claim submissions. To determine what is a covered benefit with regard to use of anti-VEGF drugs, visit aao.org/lcds to review relevant local coverage determinations. Note: The eye modifier should always be listed last when multiple modifiers are required.
MODIFIER -25 CRASH COURSE
Sue Vicchrilli, COT, OCS, OCSR
• Director, Coding and Reimbursement, American Academy of Ophthalmology
• Financial disclosure: None