Avoid the Top 10 Modifier Mistakes – Modifier 79

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Avoid the Top 10 Modifier Mistakes Modifier 79
Matching 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.
Well 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 patients 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.
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Avoid the Top 10 Modifier Mistakes Modifier 79
How its misused In some situations, its 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
Physicians 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.
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Avoid the Top 10 Modifier Mistakes Modifier 79
How you should use it Pick 79 in a situation
where the patient has returned for a second
procedure during the first procedures 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 patients
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. Example1Dr. Jones performs
cataract surgery on Mrs. Smiths right eye on
September 2, 2017, and billed 66982-RT. Dr. Jones
then performed cataract surgery on Mrs. Smiths
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 2A 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.
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Avoid the Top 10 Modifier Mistakes Modifier 79
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.