modifiers 58, 78, and 79 how choosing the wrong one could ... · the right ulna on 06/01/16...

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Modifiers 58, 78, and 79How Choosing the Wrong One Could be Costly

Maryann C. Palmeter, CPC, CENTC, CPCO, CHC10/22/2016

Objectives

Review surgical package concept per Medicare

Review modifier definitions and application to surgical procedures

Access Medicare’s payment policy indicators via CMS website

Calculate Medicare payment impact when wrong modifier applied

Global Surgical Package Concept

In general, the payment for a surgical procedure includes reimbursement for all necessary and related services before, during, and after the procedure

The post-surgical period varies based on the procedure code

Modifiers 58, 78, and 79 How Choosing the Wrong One Could be Costly October 22, 2016

Coding Fiesta 2016 Maryann C. Palmeter, CPC, CENTC, CPCO, CHC

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What’s Included per Medicare

Pre-op, intra-op, and post-op visits

Complications following the surgery that do not require a return trip to the OR

Post-surgical pain management (by the surgeon) Miscellaneous services (see next slide)

Miscellaneous Services

Dressing changes

Removal of operative pack Lines, wires, tubes, drains,

casts & splints Routine peripheral IV lines Changes & removal of

tracheotomy tubes

Insertion, irrigation & removal of urinary catheters

Nasogastric & rectal tubes

Removal of cutaneous sutures & staples

Local incision care

Other Services Excluded from the Global Package

Diagnostic tests and procedures, including diagnostic radiological procedures

Clearly distinct (unrelated) sx during the post-op period which are not re-operations or treatment for complications

Treatment for post-op complications which require a return trip to the OR (see definition)

Immunosuppressive treatment for organ transplants A more extensive procedure required when a less

extensive procedure fails



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CMS Website – Pmt Policy Indicatorshttp://www.cms.gov/apps/physician-fee-schedule/ Click on Physician Fee Schedule Search Must agree to CPT disclaimer to advance Select Year Under Type of Information, Select “All” Select HCPCs code by choosing single code, list of codes, or

range of codes Under Select Carrier/MAC, select “Specific Locality” Enter procedure code(s) Under Modifiers, select “All Modifiers” Enter Carrier/MAC Locality (0910299 – Rest of FL)

Medicare’s Global Surgery Indicators

000 = Endoscopic or minor procedure; E/M on day of procedure generally not payable

010 = Endoscopic or minor procedure with 10-day post-op period included in payment; E/M on day of procedure & during 10-day post-op period generally not payable

090 = Major surgery with a 1-day pre-op period &90-day postoperative period included in payment

Medicare’s Global Surgery Indicators

MMM = Maternity codes; usual global period does not apply

XXX = Global concept does not apply YYY = Carrier determines whether global concept applies

& establishes post-op period, if appropriate, at time of pricing

ZZZ = Code related to another service & is always included in the global period of the other service (will see w/add-on codes)



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Minor Procedures

0 or 10 follow up days

In general, minor procedures usually do not require anesthesia other than local or regional and do not require respiratory assistance

Major Procedures

90 follow up days per Medicare

In general, major procedures are usually those surgical procedures that involve anesthesia other than local or regional and may require respiratory assistance

Global Package Breakdown

Each procedure code subject to the global surgical package has:

o Pre-operative %o Intra-operative %o Post-operative %



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Procedure Code Look-up

47000

20615

6698459620

11732

47000

20615



6

20615

66984

66984



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59620

11732

Determining Duration of Global Period

Major Surgery (090)

Date of surgery is January 1

Pre-op period is December 31

Last day of post-op • period is April 1

Minor Surgery (010)

Date of surgery is January 1

No separate pre-op period

Last day of post-op period is January 11



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Global Period Exercise

Major surgery performed on 1/13/16 What would be the first date outside of the global

period?

Modifier 58

Use to bill staged or planned surgical procedures

during the post-op period of the initial procedure Do not use this modifier to report the treatment of

complications requiring a return trip to the operating room The post-op period restarts with the subsequent procedure The physician may need to document that the performance

of a procedure or service during the post-op period was:

o planned or anticipated at the time of the original procedure; o more extensive than the original procedure; or o for therapy following a diagnostic surgical procedure

Modifier 58

More extensive than the original procedure

Physician manipulates a closed, proximal end, fracture ofthe right ulna on 06/01/16 (24675-RT). An x-ray at the

follow-up appointment shows that the reductionfailed. Physician performs an open reduction withinternal fixation (24685-58-RT) on 06/15/16.



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Modifier 58

Therapy or treatment following a surgical or diagnostic

procedure

Patient’s pap smear reveals moderate cervical dysplasia

associated with HPV. Ob/Gyn physician performsconization of cervix via loop electrode excision (57522)on 05/15/16. Patient returns to OB/Gyn on 06/16/16 for

extensive cryosurgical destruction of external genitalwarts associated with the HPV(56515-58)

Modifier 78

Use when treatment for complications requires a return trip to the “OR” and the return trip falls within the post-op period of the initial surgery

Use for unplanned return trip to the “OR” for a relatedprocedure during a post-op period of the initial surgery

Post-op period for initial surgery continues If subsequent surgery is related to initial surgery but does

not require a return trip to the “OR” then it is not separately reported as it is included in the global package of the initial surgery

Medicare’s Definition of “OR”

A place of service specifically equipped and staffed for

the sole purpose of performing procedures. The termincludes a cardiac catheterization suite, laser suite, orendoscopy suite. It does not include a patient's room,

minor treatment room, recovery room, or intensive careunit.



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Modifier 79

Use when an unrelated procedure is performed by the

same physician during a post-op period The physician may need to indicate in op note that the

performance of a subsequent procedure was unrelated to the initial procedure if it is not apparent from the types of procedures performed

The post-op period restarts with the subsequent procedure Do not use for re-operations or treatment for

complications.

Payment Issues w/Surgery Modifiers

58 – new post-op period begins with planned,

subsequent procedure 78 – post-op period based on initial procedure 79 – new post-op period begins with unrelated procedure

Scenario 1

78 modifier billed on subsequent surgery but 79

modifier supported Initial surgery with 90 F/U days performed 06/01/16. Subsequent surgery with 90 F/U days performed 06/05/16.

78 modifier billed with subsequent surgery but subsequent surgery performed during post-op period of initial surgery and was unrelated to initial surgery so it should have been billed with 79 modifier.



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Scenario 2

78 modifier billed on subsequent surgery but no

modifier supported Initial therapeutic surgery with 90 F/U days performed on

06/01/16. Patient developed complication from initial surgery and

required a subsequent procedure. The subsequent procedure was performed on 06/05/16 at the patient’s hospital bedside by the surgeon and the charge was billed with a 78 modifier.

Scenario 3


modifier supported. Initial surgery with 90 F/U days performed on 06/01/16. Subsequent surgery with 90 F/U days performed on

06/05/16. Subsequent surgery related to initial surgery and required a

return trip to the OR (OR met Medicare’s definition).

Scenario 4


modifier supported Initial surgery with 90 F/U days performed on 06/01/16. Subsequent surgery with 90 F/U days performed on

06/05/16. Subsequent surgery related to initial surgery and required

return trip to OR (OR met Medicare’s definition).



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Scenario 5

78 modifier billed on subsequent, related surgery but for Medicare patients, the subsequent surgery should not have been billed with a 78 modifier because it was not areturn trip to the “OR” by Medicare’s definition. As such, it is included in the global surgical package of the initial procedure.

No modifier (58, 78, 79) would be appropriate. If Medicare paid, an overpayment may exist.

Scenario 6

58 modifier billed on subsequent surgery but 79 modifier supported, or 79 modifier billed on subsequent surgery but 58 modifier supported

Case Studies

Let’s move on to the Case Studies which were

provided as part of your handout package



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Case 1

Billed 78 modifier on 2nd surgery in global surgery package but 79 modifier supported.

Case 1 – Impact on Surgical Procedures

Allowed Amt DOS

Global Sx Pre-op %

Intra-op % Post-op %

1st Surgery $2,000 6/1/16 090 0.10 0.80 0.10

2nd Surgery $1,000 6/5/16 090 0.10 0.70 0.20

How 2nd surgery will be reimbursed:

$1000 X 0.70 = $700

(only intra-op piece of global package reimbursed when 78 modifier applied)

$700 X 0.80 = $560


Allowed Amt DOS

Global Sx Pre-op %

Intra-op % Post-op %

1st Surgery $2,000 6/1/16 090 0.10 0.80 0.10

2nd Surgery $1,000 6/5/16 090 0.10 0.70 0.20

How 2nd surgery should have been reimbursed:

$1000 X 0.80 = $800

New post-op period begins with 79 modifier and all 3 pieces of global package

(pre-op, intra-op, and post-op) reimbursed.



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2nd Sx paid $5602nd Sx should have paid $800

Net Result $240 underpayment to physician on 2nd Sx

Case 1 – Impact on E/M

Allowed Amt DOS Global Sx

post-op ends on 1st Sx

post-op ends w/78 modifier on 2nd Sx


1st Sx $2,000 6/1/16 090 8/30/162nd Sx $1,000 6/5/16 090 8/30/16 09/04/16

Allowed Amt

E/M allowed w/ 78 mod on 2nd Sx


E/M $100 8/31/16 $100 $0E/M $100 9/1/16 $100 $0E/M $100 9/2/16 $100 $0E/M $100 9/3/16 $100 $0E/M $100 9/4/16 $100 $0


Payment for post-op visits with incorrect modifier on 2nd surgery

$500 X 0.80 = $400

Payment for post-op visits with correct modifier on 2nd surgery

$0

Result: $400 overpayment to physician.



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Case 1 – Overall Impact

$400 overpayment to physician from E/M visits$240 underpayment to physician on 2nd surgery

$160 OVERPAYMENT to physician

Case 2

Billed 78 modifier on 2nd surgery in global surgery package but no modifier supported. 2nd surgery not

unrelated, not staged, and no return trip to OR.


Allowed Amt

DOS Global Sx

Pre-op % Intra-op %

Post-op %

post-op ends on 1st sx

post-op ends w/78 on 2nd sx

post-op ends w/no mod on 2nd sx

1st Sx $2,000 6/1/16 090 0.10 0.80 0.10 8/30/162nd Sx $1,000 6/5/16 090 0.10 0.70 0.20 8/30/16 8/30/16How 2nd surgery will be reimbursed:

$1000 X 0.70 = $700

(only intra-op piece of global package reimbursed when 78 modifier applied)

$700 X 0.80 = $560



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Allowed Amt

DOS Global Sx

Pre-op % Intra-op %

Post-op %




1st Sx $2,000 6/1/16 090 0.10 0.80 0.10 8/30/16

2nd Sx $1,000 6/5/16 090 0.10 0.70 0.20 8/30/16 8/30/16

How 2nd surgery should have been reimbursed: $0 2nd Sx included in global payment for 1st Sx



Net Result $560 overpayment to physician on 2nd Sx


No impact to E/M visits 8/31/16 and after. When 78 modifier applied to 2nd surgery, post-op period of 1st surgery continues. Post-op period of both surgeries ends on 8/30/16.

All E/M visits billed 8/31/16 and after will be paid.



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Case 3

Billed 58 modifier on 2nd surgery in global surgery package but 78 modifier supported.


Allowed Amt DOS

Global Sx Pre-op %

Intra-op %

Post-op %



post-op ends w/78 mod on 2nd sx

1st Sx $2,000 6/1/16 090 0.10 0.80 0.10 8/30/162nd Sx $1,000 6/5/16 090 0.10 0.70 0.20 9/4/16 8/30/16How 2nd surgery will be reimbursed: $1000 X 1.00 = $1000

$1000 X 0.80 = $800

New post-op period begins with 58 modifier and all 3 pieces of global package (pre-op, intra-op, and post-op) reimbursed.


Allowed Amt

DOS Global Sx

Pre-op % Intra-op %

Post-op %




1st Sx $2,000 6/1/16 090 0.10 0.80 0.10 8/30/162nd Sx $1,000 6/5/16 090 0.10 0.70 0.20 9/4/16 8/30/16How 2nd surgery should have been reimbursed: $1000 X 0.70 = $700Only intra-op piece of globalpackage reimbursed when 78 modifier applied.

$700 X 0.80 = $560



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Net Result $240 overpayment to physician on 2nd Sx


Allowed Amt DOS Global Sx

post-op ends on 1st Sx



1st Sx $2,000 6/1/16 090 8/30/162nd Sx $1,000 6/5/16 090 9/4/16 08/30/16

Allowed Amt



E/M $100 8/31/16 $0 $100E/M $100 9/1/16 $0 $100E/M $100 9/2/16 $0 $100E/M $100 9/3/16 $0 $100E/M $100 9/4/16 $0 $100


Payment received for E/M visits 8/31/16 through 9/4/16 with incorrect modifier 58 on 2nd surgery

$0

Payment should have been received for E/M visits 8/31/16 through 9/4/16 with correct modifier 78 on 2nd surgery

$500 X 0.80 = $400

Result: $400 underpayment to physician.



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Case 3 – Overall Impact

$240 overpayment to physician on 2nd Sx$400 underpayment to physician from E/M visits

$160 UNDERPAYMENT to physician

58 Modifier Case Study

Refer to last page in the handout for this session.

Questions



modifiers 58, 78, and 79 how choosing the wrong one could ... · the right ulna on 06/01/16...

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