The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance must be reported by using the CPT modifier 79.
Instructions
This modifier is used when an unrelated procedure or service, by the same physician, is performed during the postoperative period (10 or 90 day global) of the original procedure. A new post-operative period begins when the unrelated procedure is billed.
Correct Use
Only on surgical codes
Append modifier 79 in first position as pricing modifier
Not necessarily needing return to operating room
Failure to append could result in noncoverage
For repeat procedures on same day, append modifier 76
Incorrect Use
If Medicare Physician Fee Schedule (MPFS) indicator list marked with “XXX,” no modifier is needed as there are no global dates
Claim Coding Example
Provider performs right toe amputation on May 24, 2015.
On June 25, 2015, a left foot amputation surgery was medically necessary within this 90 day global period
Date Treatment Description CPT/Modifier
5/24/15 Amputation big toe, RT 28820 TA
6/25/15 Amputation foot, LT 28800 79
The following rules apply:
• Modifier 79 applies to surgical procedures performed on patients while they are in a postoperative period for a different, unrelated surgery. The new surgical procedure is performed to treat a new problem or injury.
• Modifier 79 is required when reporting identical procedures that are performed on the same day, but are not repeats of the same procedure on the same anatomical site.
• The unrelated procedure starts a new global period.
• Do not report with modifiers 58 or 78.
• Modifier 79 is an information modifier.
• Unrelated Procedure or Service by the Same Physician During the Postoperative Period
• Performance of a procedure or service during the postoperative period unrelated to the original procedure
• Regardless of whether the subsequent surgery required a return to the operating room
• Can only be used on surgical codes
• No additional documentation is required with the claim
• Supporting documentation must be maintained in the patient’s medical records substantiating that the surgeries were unrelated
• Allowance is based on the full fee for the procedure
Example
On May 1, a patient undergoes a complex cataract surgery (66982) on her right eye, and then has the same surgery performed on her left eye on June 1. The second cataract surgery on her left eye would be reported as 66982-79-LT.
Appropriate Usage
• To describe an unrelated procedure performed during the post-operative period of the original procedure.
• The two procedures are performed by the same physician or physician billing group.
• Pertains to all procedures codes with a 10-90 day global period.
• Modifier 79 should be appended to the second procedure.
Inappropriate Usage
• The procedure performed is related to the original procedure or a staged procedure.
• If the services performed are related to the original procedure, it is part of the global period.
Examples:
• The patient had a Diskectomy with fusion of the L4-L5 vertebrae 70-days ago. The patient tripped at home and fractured the right radial shaft. The surgeon who performed the Diskectomy is contacted and performs a closed manipulation of the radial shaft and applies a cast. The second procedure is unrelated to the first procedure. (CPT code 25505-79)
• Cataract surgery is performed on the left eye. During the global period, cataract surgery is performed on the right eye by the same physician. (CPT code 66984-79-LT).
• Patient has a repeat FEM-POP done on June 1st and is released from the hospital. A week after being home, patient is re-hospitalized on June 9th with renal failure. Hemodialysis is indicated and the same physician inserts a cannula for hemodialysis on June 10th the physician’s services for the insertion of the cannula for hemodialysis is unrelated to the FEM-POP performed during the previous hospitalization. (CPT code 36810-79).
Payment Guidelines
The longest global period for any procedure code from the original date of surgery applies to the entire surgical session and all subsequent services until the global period is complete. When using modifiers, choose the appropriate modifier for the situation, and use that modifier correctly.
The failure to use a needed modifier when appropriate may result in denial of the subsequent surgery. The incorrect use of a modifier when not appropriate may also result in denial of the subsequent surgery.
Modifiers 58, 78, and 79 are not valid to use with or attach to evaluation and management (E/M) procedure codes.
Modifiers 58, 78, and 79 are mutually exclusive to one another; only one of these modifiers may apply to a service or procedure performed within a postoperative global period.
Services may not be “unrelated” to the procedure code creating the postoperative global period and also “related” to another procedure code performed by the same physician during that same original surgical session.
Multiple Procedures During the Same Surgical Session
Modifiers 78 and 79 should not be used to distinguish multiple procedure codes performed during the same operative session. The postoperative period does not begin until the surgical session ends. This is not a valid use of modifier 78 or 79, and represents a billing error.
For example:
During the initial surgery performed by this provider, a variety of procedures are performed on multiple skin lesions in multiple locations during the same surgical session. Neither modifier 78 nor modifier 79 should be attached to the procedure codes for the second and third lesions treated. Treatment of a second, separate lesion is correctly identified with the Distinct Procedural Service modifier (-59).
** Left eye cataract removal within the global period of right eye cataract removal is unrelated; submit with modifiers 79, XS, and LT.
** Right total knee replacement within the global period of left total knee replacement is unrelated; submit with modifiers 79, XS, and RT.
** 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa) performed on the operative joint during the global period is related. Do not report with modifier 79, 58, or any other modifier (*see general anesthesia exception below).
o If performed in the office or at the bedside, 20610 is not eligible to be separately reported or reimbursed during the postoperative global period. This service is included in the global surgery package for the original surgery.
o If general anesthesia is required with a return to the operating room, then 20610 is eligible for separate reimbursement for the intraoperative work; *submit with modifier 78.
• The procedure performed is related to the original procedure or a staged procedure.
• If the services performed are related to the original procedure, it is part of the global period.
Modifier 79 applies to surgical procedures performed on patients while they are in a postoperative period for a different, unrelated surgery. The new surgical procedure is performed to treat a new problem or injury. Modifier 79 is required when reporting identical procedures that are performed on the same day, but are not repeats of the same procedure on the same anatomical site.
Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.
This circumstance may be reported by using the CPT modifier 79.
Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction).
NCCI PTP-Associated Modifiers
The NCCI PTP-associated modifiers are the following:
Anatomical modifiers: RT, LT, E1 – E4, FA, F1 – F9, TA, T1 – T9, LC, LD, LM, RC, RI
Non-anatomical modifiers: 24, 25, 27, 57, 58, 59, 78, 79, 91, XE, XP, XS, XU
The state’s claims processing system must recognize all of these modifiers and allow the PTP edit to be bypassed, if any of these modifiers is appended to the appropriate code of the edit pair with a modifier indicator of “1” and if the other conditions specified in the Claim Adjudication Rules section below are met.
Failure to do this will result in incorrect denials of payment that will be incorrectly attributed to NCCI.
After code pairs that match NCCI PTP edits in the edit file with dates of service within the effective period of the corresponding edit and with a column one code that is eligible for payment are identified, determine whether an NCCI PTP-associated modifier is correctly appended to either or both of the codes of the code pair.
Proceed as follows:
(i) If the modifier indicator of the edit is “0”, the column two code is denied (not payable) regardless of whether an NCCI PTP-associated modifier is appended. These edits cannot be bypassed.
(ii) If the modifier indicator of the edit is “1” and if no NCCI PTP-associated modifier is correctly appended to either code, the column two code is denied.
(iii) If the modifier indicator of the edit is “1” and if an NCCI PTP-associated modifier is correctly appended to an appropriate code in the edit, the PTP edit is bypassed and the column two code is eligible for payment. An exception to this rule is that if both codes have the same anatomical modifier (see above) and neither code has modifier 58, 59, 78, 79, XE, XP, XS, or XU, the PTP edit is NOT bypassed and the column two code
(iv) If the modifier indicator of the edit is “9”, both codes are eligible for payment. The corresponding edit is inactive and was deleted retroactive to its implementation dateis denied.
Guideline from UHC
Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period
Two modifiers are used to simplify billing for visits and other procedures that are furnished during the postoperative period of a surgical procedure, but not included in the payment for surgical procedure.
• Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.
Return to the OR for a Related Procedure during the Post-Operative Period
When treatment for complications requires a return trip to the OR, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, i.e., CPT code 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.
In addition to the CPT code, physicians report modifier “-78” (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 physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. 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.
When a CPT code billed with modifier “-78” describes the services involving a return trip to the operating room to deal with complications, pay the value of the intra-operative services of the code that describes thetreatment of the complications. Refer to Field 18 of the MPFS to determine the percentage of the global package for the intra-operative services. The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent.
When a procedure with a “000” global period is billed with a modifier “-78,” representing a return trip to the operating room to deal with complications, pay the full value for the procedure, since these codes have no pre-, post-, or intra-operative values
Procedures billed by the same provider within the postoperative period of an original
procedure are considered part of the global surgical package. Modifiers that indicate related or unrelated procedures during the postoperative period are 58, 78 and 79. In order to receive reimbursement for related or unrelated procedures during the postoperative period, modifier 58, 78 or 79 must be appended to the procedure code. Procedures are considered outside of the global package if they are:
1. a related or staged procedure (modifier 58),
2. a procedure requiring a return trip to the operating room during the postoperative period (modifier 78), or
3. an unrelated procedure during the postoperative period (modifier 79).
If one of these modifiers is not appended, the service will be denied as included as part of the global period. Modifier 58 is used only if the procedure is billed by the same provider within the postoperative period of the original procedure, and is used by the operating surgeon only.
Procedures billed by the same provider within the postoperative period of an original procedure are considered part of the global surgical reimbursement package. Modifiers that indicate related or unrelated procedures during the postoperative period are 58, 78 and 79. In order to receive reimbursement for related or unrelated procedures during the postoperative period, modifier 58, 78 or 79 must be appended to the procedure code. Procedures are
considered outside of the global package if they are:
1. a related or staged procedure (modifier 58),
2. a procedure requiring a return trip to the operating room during the postoperative period (modifier 78), or
3. an unrelated procedure during the postoperative period (modifier 79).
If one of these modifiers is not appended, the service will be denied as included as part of the global period.
Modifier 78 is used if a procedure is billed by the same or different provider within the postoperative period of the original procedure, and requires a return trip to the OR. An operating room is described as a place of service specifically equipped and staffed for the sole purpose of performing procedures. This can include cardiac catheterization suites, laser suites, endoscopy suites and ambulatory surgery centers. It does not include a patient’s room, a minor treatment room, recovery room or special care unit such as CCU, ICU,or NICU.
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Applicable Providers
• Physicians, all specialties
• Optometrists
• Podiatrists
• CRNA
• Multi-specialty Clinics
• Planned Parenthood
• Nurse Practitioners
• Nurse Midwives
General Information
Modifier 79 is used with major or minor surgical procedures to indicate an unrelated procedure was performed by the same provider during a postoperative period of the original procedure.
If the unrelated procedure has postoperative days, the follow-up period will start over with the new procedure. Policy Procedures billed by the same provider within the postoperative period of an original procedure are considered part of the global surgical reimbursement package. Modifiers that indicate related or unrelated procedures during the postoperative period are 58, 78 and 79. In order to receive reimbursement for related or unrelated procedures during the postoperative period, modifier 58, 78 or 79 must be appended to the procedure code. Procedures are considered outside of the global package if they are:
1. a related or staged procedure (modifier 58),
2. a procedure requiring a return trip to the operating room during the postoperative period (modifier 78), or
3. an unrelated procedure during the postoperative period (modifier 79).
If one of these modifiers is not appended, the service will be denied as included as a part of the global period.
Modifier 79 is used when an unrelated procedure is billed by the same provider within the postoperative period of the original procedure.
Billing • Modifier 79 indicates the procedure is unrelated to the original service or procedure. Example: A total knee replacement (27447) is performed. Within the 90-day follow-up for the knee replacement, care for a colles fracture of the wrist (25620) is provided. Procedure code 25620-79 should be submitted.
• Modifier 79 is intended for use by the operating surgeon only.
• Modifier 79 is appended to major and minor surgical procedures only. It is not to be used on evaluation and management (E/M) codes.
• All unrelated procedures performed within the postoperative period should be billed with modifier 79. (E.g., if three unrelated procedures are rendered, all three are appended with modifier 79. If they are rendered on the same day, one is identified as the primary with no modifier 51 and the other two “secondary” procedures are further appended with modifier 51 to designate multiple procedures.)
Modifier 79 is used with surgical procedures to identify a procedure or service by the same physician during the postoperative period of another unrelated procedure. This modifier should be submitted when an unrelated subsequent service is performed by the same surgeon within the global period of a major or minor surgery.
The 79 is used on the 2nd procedure when there is a global period on the 1st code. It does not matter whether a global period exist on the 2nd code.
Please note: Use modifier 78 if the subsequent surgery is related to the initial surgery and required a return to the operating room, and both are performed by the same surgeon.
If the subsequent surgery is related to the initial surgery but does not require a return to the operating room, and both are performed by the same surgeon, do not submit separately. Additional related surgical procedures that do not require a return to the operating room are included in the global fee for the initial surgery.
Coding Guidelines
• All codes on the major and minor lists can be billed with modifier 79 with the exception of the multiple session codes listed below. Major surgery and minor surgery code lists are published in the April, 1999 Medicaid bulletin.
• Multiple session codes should not be used with modifier 79. The following codes describe procedures that require one or more services in order to complete the procedure.
The fee schedule amount allows for each segment included in the procedure, therefore, additional reimbursement cannot be given per session.
65855 66761 66762 66821 66840 67031 67101 67105 67141 67145 67208 67210 67218 67220 67227 67228
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Day Care Centres
A patient undergoes a Total abdominal colectomy with end-ileostomy. and than is undergoes a reversal of ileostomy with in the global period which modifier do I use 78 or 79??
A patient has a Total abdominal colectomy with end-ileostomy. And than undergoes a reversal of ileostomy within the 90 day global, which modifier should I use? 78 or 79.