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What do you Understand by the Modifiers 58, 78 and 79?

December 24, 2015

What do you Understand by the Modifiers 58, 78 and 79?

When certain procedures are performed within what is called the “global period” of another procedure certain modifiers, specially Modifiers 58, 78, and 79, are called into usage. Although, all are used in conjunction with the above procedural scenario, and are very similar in definition, yet they differ in scope and usage. According to the definition of the Current Procedural Terminology (CPT®) surgical package there are integral services that take place during the preoperative period; procedure or surgery; and normal, uncomplicated postoperative care; and are included in every procedure that cannot be reported or billed separately. However, if the same operating physician performs services within the surgical package that do not qualify as normal postoperative care, modifiers 58, 78, and 79 are appended, and differ based on their verbiage.

The Medicare Fee Schedule Database (MFSDB) global surgery indicator identifies CPT procedures as having one of the following global periods:

000 Zero day Medicare global period
010 10-day Medicare global period
090 90-day Medicare global period
YYY Global period is set by the carrier
ZZZ Add-on codes that are always billed with another service

We all understand that these three modifiers have reference to the verbiage “related procedure” and “during the post-operative period” within their definitions. This confusion can be thus sorted by understanding the specific role each modifier plays and needs to be appended in the correct situation to speed the healthcare claim via the adjudication process to payment from the insurance carrier. A further cautionary step that needs to be ascertained before applying any of the three modifiers is that, they reset or restart the “global service days” for the service or procedure (e.g., a new postoperative period begins when the next service or procedure in the series is billed).

Let’s get to understanding how the Modifiers 58, 78, and 79 work and help make the Revenue Cycle Management process a success

Modifier 58:
is appended for a “staged or related procedure” or “service by the same physician or other qualified healthcare professional” during the postoperative period.

Medical coders, when appending this Modifier 58, need to be aware that the provider performed a procedure or service during the postoperative period and that it was:

  • planned or anticipated (staged)
  • more extensive than the original procedure
  • for therapy following a surgical procedure

Medical coders and physicians who are making notes and involved in the documentation, should be aware not to append modifier 58 to CPT codes that include multiple sessions or any services that could be part of the initial service. Further, Medicare adds an additional requirement - a return to the operating room (OR) is a must if applying modifier 58. A new “global period” begins for the second surgery, and most payers will thus reimburse the second surgery based on 100 percent of the fee scheduled. Thus, Modifier 58 may only be used during the “global surgical period” for the original procedure.

Modifier 78: is used for an unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period. Modifier 78 contains verbiage that was updated to reflect an “unplanned return to the operating room/procedure room”. A procedure room can be one that is located in a physician office, ambulatory setting, or a formal operating room setting

Hence Modifier 78 can be used only when it is indicated that another procedure was performed during the postoperative period of the initial procedure and that it was an unplanned procedure following the initial procedure. So Medical Coders need to read the documentation carefully and add modifiers 78 only when the consequent procedure is related to the first, and requires the use of an operating/procedure room. It is critical to healthcare providers, physicians, etc to use verbiage correctly, to help coders get it right when appending the modifier 78. Coders need to look for

  • the word unplanned. Without the proper physician documentation which must show that the procedure or surgery was unplanned with respect to the original procedure or service.
  • the unplanned surgery/procedure must be performed by the same physician who performed the original procedure.

A crucial point to take into consideration and hence documentation is vital here, specifically when appending Modifier 78 - it does not reset global days from the previous surgery. Medical coders and billers should be aware that when appending Modifier 78, the procedure usually is not reimbursed at 100 percent of the allowed amount and often depends on the carrier’s guidelines. However, some carriers may reimburse just the intra-operative portion of the fee scheduled payment. When applying modifier 78, attention should also be paid to the diagnosis, which is usually different for each procedure.

Modifier 79: is used to report an unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period.

Thus, when medical coders decide to append modifier 79, they need to be acutely aware that:

  • the service/procedure must be an unrelated procedure
  • or service performed by the same physician within a postoperative time frame.

The distinguishing and crucial difference between modifier 78 and modifier 79,

  • Modifier 78 for a related procedure; modifier 79 for an unrelated procedure
  • Modifier 78 can be appended only if procedure is in an operating room; modifier 79 does not require that the service/procedure be performed in an operating room
  • Unlike Modifier 78, medical Coders do need to append modifier 79 if the same physician performs an unrelated procedure within a postoperative time frame.

Modifier 79 may override payer edits that would include this procedure as part of the previous surgery.

Thus, understanding not just the verbiage that is contained in the definitions of modifiers 58, 78 and 79, but also the physician and all healthcare providers documentation notes; will help expedite a clean claim and thereby improved reimbursements.

The above Medicare fee Schedule box is just an explanatory box for global periods explanation and can be placed as shown. Please do the formatting accordingly

This below box can be put alongside when the modifiers are being explained

Modifier Append to Claim When
Modifier 58 A "more extensive" procedure or procedures in stages, is conducted in a postoperative period and conducted by same physician or other “qualified healthcare professional”
Modifier 78 Complications follow the original surgery and patient requires additional surgery and is returned to the operating room.
Modifier 79 An unrelated surgery to the original surgery when patient comes in especially during the postoperative period and is attended to by the same physician

Category : ICD-10 Coding