Orthopedic coding is always tricky because joints are some of the complex parts of the body. But CPT guidelines, American Academy of Orthopedic Surgeons (AAOS) Global Service Data, and the National Correct Coding Initiative (NCCI) edits don’t seem to make life any easier for the orthopedic coder. One way to get the tiger by the tail is to master common modifier mistakes.
In addition to keeping up with all the new and deleted codes, there are also several modifiers coders must keep track of, and the wording of some of them can make it difficult to decide which one to use. However, by teasing out the differences, you can create accurate claims that will be hard for insurance companies to deny.
Planned vs. Unplanned Second Procedures
Two modifiers that often confound coders are -58 and -78. Both deal with second procedures performed in the postoperative period. Before delving into the subtleties of these two modifiers, here’s a little more detail on when to report -58:
- When the second procedure was planned or anticipated within reason
- When the second procedure was more intensive than the first
- For therapy following the first surgical procedure
It’s important to highlight here “planned or anticipated.” It’s simple to tell if the patient’s report explicitly says so, but here “planned or anticipated” can also indicate a second procedure that could have been reasonably expected to be needed. After all, doctors cannot predict everything.
Take, for example, a patient who undergoes a diagnostic arthroscopy. If the physician then decides an open procedure is needed, -58 can be attached to the open procedure, as it can be shown that the open procedure was planned or expected within reason. As with every aspect of the medical report, the medical necessity for both procedures must be documented.
According to the Global Surgery Booklet distributed by the Centers for Medicare & Medicaid Services (CMS), -58 is used to report a “staged or related procedure or service by the same physician during the post-operative period,” while modifier 78 is used to report an “unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period.” The wording between these two is so similar it can be hard to pick out the differences during a busy day creating claims, leaving many coders reasonably confused.
Tips for Choosing the Right Modifier
When reading a physician’s report, the key thing to look for first is whether or not the second procedure was planned, as mentioned above. Additionally, here are a couple quick tips to pick out which modifier is appropriate:
- If the second procedure required the use of an operating room, use -78.
- If the second procedure was due to a complication in the first procedure, select -78, but if it was to further correct a patient’s underlying condition, use -58. The word “related” in the definition of -58 refers to the patient’s initial or underlying condition, whereas in -78 it refers to the initial procedure.
While the wording is similar, the amount reimbursed for each modifier is not. Modifier 58 initiates a new global period, and provides full reimbursement, whereas with -78 a new global period is not begun, and reimbursement is reduced since the second procedure was due to a medical complication.
Distinct Procedures on the Same Day
And now, modifier 59. This is one of the modifiers most susceptible to audits, as it is one of the most overused, even in orthopedics. A quick look at what -59 is will show why.
Modifier 59 is used to recognize (non-E/M) procedures that aren’t usually reported together, but can be under the provided circumstances. Because this overrides edits in the insurance carrier’s system, auditors have reasonable suspicion that some coders may be bundling together two separate services for reimbursement when it’s not appropriate to do so.
So how to know when use of -59 is appropriate? Basically:
- The patient’s medical record must report that each procedure was separate, as the insurance carrier may (fairly) request to see the record before providing reimbursement.
- This modifier should be used when two separate procedures were performed during the same visit but on two separate body parts.
- No other modifier can better describe the services provided.
However, when using -59, keep in mind that private carriers may have different interpretations of NCCI edits, so be sure to have a thorough knowledge of each payer’s policies before submitting claims with this modifier.
Identifying Appropriate Modifiers with Ease
Coding can be stressful, especially with all the changes being made to codes, modifiers and guidelines, but keeping up-to-date on the latest news makes for a knowledgeable coder who will be invaluable to any orthopedic practice. Orthopedic coding expert Lynn Anderanin shares her depth of knowledge in “Learn about the Coding Guidelines, NCCI Edits and Policy Manual for Orthopedic Claims,” a webinar with ProfEdOnDemand. Intended for coders, surgery schedulers, billers and providers, Lynn focuses on proper modifier usage, NCCI policy manual guidelines, and creating claims that will be complete enough to avoid denials. Equipped with her knowledge, coders and practices will become better experts on key areas typically tricky for orthopedic coding.
