ASC Compliance & Coding

Modifier Madness

By Riva Lee Asbell

For Medicare, surgical coding and reimbursement are ultimately controlled by modifiers. This is true for both physicians and facilities. This review addresses modifier usage in ASC coding.

The complete listing of modifiers and their descriptions is found in the CPT appendix “Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use”. Their usage isn't always the same as in physician surgical coding so there are certain caveats.

Specifics of Modifier Usage in the ASC

SG MODIFIER

The SG modifier is not to be appended effective with the new system in 2008.

MODIFIER 50

Do not use modifier 50. Although it appears in the appendix, it should not be used. Medicare contractors have issued instructions regarding this. Instead, use a two-line entry with a single unit of service on each line or two units of service on a single line. Use of modifier 50 will result in payment for only one side when bilateral surgery is performed.

MODIFIER 51

Use this for multiple procedures — it is added after the first procedure. Not all Medicare contractors/carriers require its use; however, you won't be penalized for using it.

MODIFIER 52

Modifier 52 has a special use in ASC coding that differs from what is published in CPT. It's used for coding reduced services for discontinued radiology procedures and other procedures not requiring anesthesia that are partially reduced or discontinued at the physician's discretion. In this usage, the payment is 50% of the allowed amount.

MODIFIER 59

Use of Modifier 59 is notorious for engendering audits and should be used with the utmost care since it is perennially on the OIG's (Office of Inspector General) list for audits.

Your documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

MODIFIERS 73 AND 74

Modifiers 73 and 74 are ASC-specific modifiers that are often overlooked. Modifiers 73 and 74 are used when a procedure is terminated. In contrast, for physician coding, a discontinued procedure is coded by appending modifier 53.

The difference between Modifier 73 and Modifier 74 is that modifier 73 is to be used prior to anesthesia administration but not when there is an elective cancellation of the procedure. The surgical or diagnostic procedure may be cancelled subsequent to surgical preparation, but before the administration of anesthesia. Payment is at 50% of the allowable amount for the procedure.

Modifier 74 is used after the procedure has commenced or after the anesthesia was administered. Payment is at 100 % of the allowable amount for the procedure.

MODIFIERS 58, 78 AND 79

Before proceeding, please read the definitions of these modifiers in Table 1. They're used for engendering payment for procedures performed in the global period of another surgery.

Append modifier 79 to a subsequent surgery performed in the global period when it is unrelated to the first surgery by virtue of many issues including: different site, different diagnosis, different clinical manifestation and problem. The procedure should be unrelated to the original surgery in a significant way. Examples:

• Procedure performed on the contralateral eye (different site)
• Procedure performed by another surgeon of a different subspecialty (anterior segment followed by retina surgeon — usually a different area of the eye)
• Procedure performed for traumatic injury following routine procedure (different problem)

Modifier 78, on the other hand, is used when the second surgery in the global period is somehow related to the first — usually from a complication. It's also used for coding a subsequent procedure performed in the global period when an additional surgery is required that's of the same level or lower complexity as the original surgery. Examples:

• Evacuation of hyphema after cataract surgery
• Retina cryo or photocoagulation for the same condition after complex vitrectomy and associated procedures were performed
• Intravitreal injection following a more complex procedure

Modifier 58 is used in three very different situations. It's not used for coding complications or related procedures. Examples:

• Lesser to greater: aqueous shunt performed after trabeculectomy
• Staged procedure: severing of the eyelids performed after a reconstruction of the eyelid such as Hughes procedure
• Diagnostic to therapeutic: for vitrectomy performed after vitreous tap through paracentesis

CASE EXAMPLES:

CODING Q & A

Q. I have a question about coding an ASC surgical procedure. The surgeon removed a perforating corneal foreign body (was planning on using 65280 & 870.4) and the patient was taken to the postoperative area. The wound was found to be leaking, so the surgeon decided to take the patient back to the OR for application of glue/Tisseel. The patient was not sedated upon return to the OR, nor were anesthesia services requested. The OR setting was only used to apply the glue in a sterile environment. I wanted to add the 65286 code – do I append a modifier? I see that modifier 78 does not apply to ASCs.

A. There is no Category I CPT code for applying glue for closure of a surgical wound; in fact, CPT instructions state specifically that 65280 and 65285 (repair of corneal/and or scleral lacerations with and without reposition of uveal tissue, respectively) are not used for repair of a surgical wound. Thus, you would need to use 66999; however, unlisted codes are not payable to an ASC. Modifier 78 is an ASC modifier and the one that would be used with a Category I CPT code.

Q. We had to perform an IOL exchange for a dislocated IOL. The patient was 2 weeks post-cataract surgery when the lens dislocated. I'm confused about what modifier to append. 79, 78 or something else? Thanks.

A. Since the exchange was related to the original surgery, you would use modifier 78.

Q. A zonular dehisence occurred during cataract surgery, so the surgery was stopped, and a retina specialist performed a pars plana lensectomy and vitrectomy. The patient is now scheduled for insertion of a secondary IOL. Modifier 58 or 78?

A. The secondary IOL insertion is related to the first operation and therefore modifier 78 is the correct one. ◊