How to differentiate between Modifier 58, 78 & 79



Modifier 58- 
Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

    Report when a procedure or service during the postoperative period was:
    Planned prospectively or at the time of the original procedure
    More extensive than original procedure
    For therapy following a diagnostic surgical procedure                                
    When performing a second or related procedure during the postoperative period
    • Modifier 58 indicates the physician, or member of the same group, planned the performance of a procedure or service during the postoperative period prospectively or at the time of the original procedure.
    • Bill modifier 58 with the subsequent performed procedure
    • Use during the post-operative period starting the day after the initial procedure.
    • Not appropriate for services performed on a single date of service.
    • Not appropriate when the MPFSDB indicates XXX global period.
    • Not appropriate with assistant at surgery
    • Not appropriate for Ambulatory Surgical Center’s Facility fees
    How to differentiate between Modifier 58, 78 & 79


    Modifier 78  
    Return To The Operating Room For A Related Procedure During The Post Operative Period

      Use to identify a related procedure (that has a 000, 0010, 090 or YYY, global surgery indicator) requiring a return trip to the operating room on the same day as or within the postoperative period of a major or minor surgery.
      Use to treat the patient for complications resulting from the original surgery
      When the procedure code used to describe a service for a treatment of complications is the same as the procedure code used in the original procedure.
      • Used to indicate the performance of a procedure during the postoperative period or on the same day as the original procedure to treat complications, which required return to the operating room
      • Bill modifier 78 with the CPT code describing the procedure(s) performed during the return trip.
      • Only use the procedure code for the original procedure if the identical procedure is repeated.
      • When the procedure code used to describe a service for treatment of complications is the same as the procedure code used in the original procedure, modifier 78 is still the correct modifier to use.
      • Modifier 78 reimbursement is intra-operative percentage only.
      • Use Modifier 78 to document treatment of complications only.
      • Use Modifier 78 to indicate services furnished in an operating room (OR). OR definition, for this purpose, is a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, laser suite, or endoscopy suite. It does not include a patient’s room, minor treatment room, recovery room, or intensive care unit.
      • Does not apply to assistant at surgery services
      • Does not apply to Ambulatory Surgical Centers facility fees
       
      Modifier 79 Unrelated Procedure or Service by the Same Physician During the Postoperative 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.
      • Modifier 79 indicates the performance of a procedure or service during a post-operative period was unrelated to the post-operative care of the original procedure.
      • Bill Modifier 79 with the procedure performed.
      • Do not bill when the MPFSDB indicating XXX in the post-operative field.
      • Use modifier 79 on services during the post-operative period starting the day after the procedure.
      • Does not apply to assistant at surgery services
      • Does not apply to Ambulatory Surgical Center's facility fees

      When to use Modifier 54, 55 and 57 with CPT codes


      Modifier 54 Surgical Care Only

      Used to indicate when one physician or other qualified healthcare professional performs the surgical care only and another physician performs the pre-operative or post-operative care, each belonging to a different practice. 

      Reimbursement will be 70% of the provider’s applicable Fee Schedule allowed amount.

      • Modifier 54 indicates the surgeon is relinquishing all or part of the postoperative care to a physician outside the same group.
      • Bill modifier 54 with the CPT code describing services furnished.
      • Applies to MPFSDB codes that include 010 or 090 global periods
      • CMS defines the modifier 54 differently than CPT 4 by including reimbursement of all preoperative care, the intra-operative surgical service, and all hospital postoperative care.
      • The surgeon must keep a copy of the written transfer agreement in the beneficiary's medical record.
      • Modifier 54 does not apply to assistant at surgery services.
      • Modifier 54 does not apply to Ambulatory Surgical Center's facility fees.
      When to use Modifier 54, 55 and 57 with CPT codes



      Modifier 55  Postoperative Management Only

      Used to indicate when one physician or other qualified healthcare professional performs the post-operative management only and another physician performs the surgical care, each belonging to a different practice. 

      Reimbursement will be 20% of the provider’s applicable Fee Schedule allowed amount.

      • The surgeon who furnished a portion of the outpatient postoperative care and the physician, other than the surgeon, who furnished postoperative management services bill with the 55 modifier.
      • Bill modifier 55 with the CPT code describing the surgical procedure
      • Bill modifier 55 for procedure codes with MPFSDB global periods of 010 or 090
      • Codes billed must show the date of surgery as the date of service, also indicate the date care was relinquished / assumed.
      • Keep copies of the written transfer agreement in the physician furnishing the postoperative cares beneficiary's medical record
      • Provide at least one service before the receiving physician can bill for any part of the postoperative care.
      • Not appropriate for assistant at surgery services
      • Not appropriate for Ambulatory Surgical Center's facility fees.

      Modifier 57  Decision for Surgery

      • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
      • E/M service resulting in the decision to perform the surgery on the day before major surgery or on the day of major surgery (90 day post op) is not included in the global surgery payment and is separately billable.
      • Bill Modifier 57 with the appropriate E/M code identifying a visit that resulted in the initial decision to perform surgery
      • Do not bill Modifier 57 in connection with minor surgeries because the decision to perform the minor procedure is done immediately before the service it is considered a routine preoperative service.
      • Bill modifiers 24 and 57 when furnishing an E/M service resulting in the initial decision to perform major surgery during the postoperative period of another, unrelated, procedure
      • Modifier 57 is not reportable for preplanned or prescheduled surgeries, or if the surgical procedure indicates performance in multiple sessions or stages.

      Best coding guide for CPT code 74270 & 74280

      In Radiology, their are many procedure codes which are very different from others. Some of them need lot of attention because of their complex nature. 

      Today, I would like to share some coding tips for CPT code 74270 and 74280 which have always confused me during my initial coding days. Below are their full coding description.


      74270 - Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB
      74280 - Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon
      If you want to differentiate between CPT code 74270 & 74280, just look for the use of single and double (air) contrast in the procedure. 
      Best coding guide for CPT code 74270 & 74280


      Procedure performed for Barium Enema code 74270 & 74280


      A lower GI series, or barium enema, is an X-ray test in which a contrast agent or a white liquid, called barium, is placed into the rectum and colon through the anus to enhance x-ray pictures of the large bowel (colon). These X-rays are used to define normal and abnormal anatomy of the colon and rectum
      The enema is given to instill the contrast agent, which coats the lining of the colon. Fluoroscopy and x-ray images are taken to study to colon and look for abnormalities, such as growths or inflammation, and help diagnose conditions such as cancer or colitis. After the patient voids the colon, more x-rays are taken, which may include the abdomen when a KUB is also done.

      Common diagnosis for performing Barium Enema (CPT code 74270 & 74280)

      • abdominal pain
      • blood in your stools
      • a change in your bowel movements
      • Crohn’s disease
      • chronic diarrhea
      • colorectal cancer
      • diverticulitis


      Top Modifiers billed with CPT code 74270 & 74280


      26 Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.

      Don’t append a –26 when the physician owns his own equipment.Bill globally (ie, for both the professional and technical components of the service).

      TC (Technical Component) is used assigned to a procedure code when the provider rendered only the technical component of the service.

      GC  This service has been performed in part by a resident under the direction of a teaching physician

      Coding tips for CPT code 93971 & 93970


      Ultrasound is a procedure that uses sound waves to "see" inside your body. This procedure is performed to evaluate symptoms including leg pain or swelling, excessive varicose veins, shortness of breath, or suspected blood clots in your legs and/or lungs.  

      Duplex ultrasound is a non-invasive evaluation of blood flow through your arteries and veins. This test provides information to help your vascular physician make a sound diagnosis and outline a treatment plan. 

      Duplex ultrasound successfully identifies 95 percent of deep vein thromboses that occur in the large veins above the knee.

      Coding tips for CPT code 93971 & 93970


      Read also: When to use CPT code 76881 and 76882

      Description of CPT code 93970 and 93971


      For evaluation of extremity veins for venous incompetence or deep vein thrombosis, use CPT codes 93970, duplex scan of  extremity veins; complete bilateral study or 93971, unilateral or limited study.



      93970 - Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

      93971 - Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study


      93965 - Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) (deleted in 2017)

      G0365 - Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow)

      Medicare has created code G0365 to be used for vessel mapping performed in conjunction with the creation of an autogenous hstula for hemodialysis access. The code includes evaluation of the relevant arterial and venous vessels.  


      Read also: Best coding tips for CPT code 78451 and 78452

      Do and Don't with CPT code 93970 and 93971



      Use RT & LT modifier for unilateral CPT code 93971

      Do use CPT code 93970 and 93971 for upper and lower extremity veins exams.

      Do use 59 or X{EPSU} modifiers with 93971 and 93970 when the exams are performed on both (upper and lower) extremities.



      Bill Type Codes

      Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

      11x    Hospital Inpatient (Including Medicare Part A)
      12x    Hospital Inpatient (Medicare Part B only)
      13x    Hospital Outpatient
      18x    Hospital - Swing Beds
      21x    Skilled Nursing - Inpatient (Including Medicare Part A)
      22x    Skilled Nursing - Inpatient (Medicare Part B only)
      23x    Skilled Nursing - Outpatient
      28x    Skilled Nursing - Swing Beds
      83x    Ambulatory Surgery Center
      85x    Critical Access Hospital

      Top common mistakes done by medical coders during CPC exam



      As a medical coder, you always want to be get certified either from AAPC or AHIMA. There are lot of advantages once you become a certified medical coder from AAPC or AHIMA. The most common exam to which medical coders tend to clear is CPC exam.

      Certified professional Coder (CPC) exam consist of 150 objective questions. The time limit is 5 hours and 40 minutes. Two attempts are given to clear the CPC exam.

      I have seen many coders who have the capability to clear this exam, but fails in both the attempt. The coders tend to do lot of silly mistakes which leads to decrease in the score of CPC exam.

      Let us check some of the common mistakes coder do during the CPC exam, which can be easily avoided.

      Top common mistakes done by medical coders during CPC exam



      Overlooking the options or answers


      For each question, there are 4 options to find the correct answer. Most of the times the coders do not look all the options correctly and choose the wrong answer. For example, if a liver biopsy medical report is given and gave four options for coding liver biopsy (47000) with ultrasound guidance.

      The options will include ultrasound guidance (CPT code 76942) code. But, there is another ultrasound guidance code 76937 will also be given to confuse medical coders.

      CPT code 76937 is used only with vascular procedures, while CPT code 76942 is used for non-vascular procedures.

      If your do not focus on other options, you will choose the incorrect ultrasound guidance code 76937 instead of 76942. Hence, presence of mind is also very important during CPC exam for solving each question.

      Managing time during CPC exam


      Time runs very fast during CPC exam. Most of the medical coders do not take the first two hours seriously and answers only few questions. This leads to decrease in the time required for other questions and hence due to less time they are not able to find the correct answers.

      If you do not manage time during CPC, you will surely fail in this exam. Hence, during preparation of CPC Exam, try to solve some model question papers of CPC exam. This will help you in managing the time and answering all the question before time.

      I would suggest you to solve the questions first which are easy for you. If you are confident about solving any question solve that first and then go for the complicated one.  Even if you solve 70% of questions confidently, your probability of passing the CPC exam increases to 90%.

      Hence, do manage your time carefully and solve the CPC exam paper cleverly.


      Failing to attempt all the questions


      CPC exam has no negative markings. Now, this is the best advantage to clear this exam. Most of the coders do not attempt all the questions and then fails the CPC exam with just few marks.

      During CPC exam, this is the most important thing to follow that we have to finish the question paper before half an hour of the exam.

      Even if you answer 60% of questions correctly and rest 40% is you have randomly answered, then also you have a hope to get at least 10% correct answers from randomly selected answered.

      If you do not answer the questions, then there is no hope also to clear this exam.

      Always remember, you have to get equal or more than 70% to clear CPC Exam. Hence, you have to be very clever to achieve that passing percentage.