Avoid the Top 10 Modifier Mistakes – Modifier 79

Avoid the Top 10 Modifier Mistakes – Modifier 79Matching CPT code with an ICD 10 code, this would seem to be a very straightforward process but there are always variations/exceptions to everything. Sometimes, there are related services that the physician is performing, global periods to contend with, etc. Modifiers will clarify extenuating circumstances, which should allow for payment when they otherwise may not. That said, the improper use of modifiers can be the cause of claim denials just as not using a modifier can be. When using modifiers, make sure you clearly understand what the modifier entails.

In this, and the following blogs, we identify 10 of the most commonly misused modifiers to help you become more aware of the issues surrounding them. We’ll help you understand why they are problematic and how you can use them correctly.

Modifier 79

Modifier 79 is defined by CPT as “unrelated procedure or service by the same physician during the post-operative period.” It is used in the strictest sense for care that is entirely unrelated to the prior surgery that created the current global period.

Modifier 79 is an informational modifier. No additional documentation is required to be submitted with the claim. Supporting documentation must be maintained in the patient’s medical record and must substantiate that the surgeries are unrelated. When appending modifier 79, it is important to keep in mind that this modifier re-sets the global period. A new post-operative period begins when the unrelated procedure is billed.

How it’s misused:
In some situations, it’s easy to confuse modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) with modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional), 78 (Unplanned return to the operating/procedure room by same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period), or 58 (Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period).

The procedure performed is related to the original surgery or staged (anticipated) surgery. Placed on procedure codes with XXX, (Global concept does not apply), in the GLOB (global) field of the MPFSDB (Medicare Physician’s Fee Schedule Database). If related to the original procedure, it is considered part of the global period.

To describe an unrelated surgical procedure performed during the post-operative period of the original procedure by the same physician. When reporting identical procedures that are performed on the same day, by the same physician, but are not the same service on the same anatomical site.

How you should use it: Pick 79 in a situation where the patient has returned for a second procedure during the first procedure’s global, or postoperative period, and the reason for the second service has no relationship to the reason for the first. You would use 76, 78, or 58 when the second procedure is related to the first in some way — 76 when a provider administers a second, identical service after the first service did not significantly improve the patient’s condition, 78 when complications arise from the first procedure, and 58 if the first procedure is a precursor to the second. But more of that in our next post.

Example1:
Dr. Jones performs cataract surgery on Mrs. Smith’s right eye on September 2, 2017, and billed 66982-RT. Dr. Jones then performed cataract surgery on Mrs. Smith’s left eye on October 2, 2017. Since the second cataract surgery was performed within the 90 days post-operative period of the first surgery, Dr. Jones would report 66982-79LT. The use of modifier 79 on the second surgical procedure would be appropriate because the surgery is unrelated because it was performed on a different eye.

Example 2:
A 19-year-old man falls and breaks the shaft of his tibia. The orthopedist performs an open reduction of the fracture. Two weeks later, the patient trips while going down the stairs with his new cast and breaks his ulna. He returns to the same orthopedist, who performs another open reduction on the new fracture during the global period of the previous procedure.

Since the procedures are completely unrelated, you should report 27758 (Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage) for the tibia fracture repair. Then, report 25545 (Open treatment of ulnar shaft fracture, includes internal fixation when performed) for the ulna fracture repair with modifier 79 appended to show that the tibia and ulna repair were unrelated surgeries and that the ulna treatment occurred within the 90-day global period for the tibia repair.

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