Billing for Surgical Complications: Modifiers -58, -78 and -79

Close up of an Eye - ophthalmology, medicalOccasionally a patient may experience a surgery complication that will require additional treatment. The payment for the initial surgery also includes post-op care during the global period (excluding testing). Under Medicare, the global period includes a postoperative time period for minor surgeries that can be either 0 or 10 days. For major surgeries the global period is 90 days.

Services that are covered during the global period include:

  • preoperative visits beginning the day prior to surgery (for major surgeries) and the day of surgery (for minor surgeries). The exam to determine the need for a major surgery would include modifier -57 appended to the exam code.
  • intraoperative services that are typically necessary and part of the surgical procedure.
  • complications following surgery, unless it is necessary to return to the operating room/procedure room.
  • postoperative visits during the duration of the postoperative period.
  • supplies.
  • related visits in the hospital.
  • related visits in an ASC.
  • related visits for critical care services.

Modifier -58: Staged or related procedure or service by the same physician during the postoperative period. You can use this when the later intervention was:

  • More extensive than the original procedure.
  • Planned and documented at the time of the original procedure.
  • Injection given in the lane – this does not apply to laser codes that include “per session” or “one or more sessions” as part of their CPT descriptor. Payment is 100% of the allowable and a new global period begins.
  • For example, a patient presents during the postop period of a trabeculectomy in the right eye and receives a therapeutic injection of 5-FU. Use code 68200, -58, -RT for the subconjunctival injection and J9190 for the fluorouracil.

Modifier -78: Unplanned return to the operating/procedure room by the same physician or other qualified health professional following initial procedure for a related procedure during the postoperative period.

  • Payment for surgical codes is divided into three parts, with the pre-, intra- and postoperative components being allocated 10%, 70% and 20% of the allowable, respectively. When modifier -78 is appended, payment is made at 80% of the allowable. Since this payment doesn’t include the postoperative component’s 20%, a new postop period does not begin. The global period of the original surgery is the only one in effect.
  • For example, a YAG laser capsulotomy is performed in the right eye during the global period of cataract surgery in the same eye. Use code 66821 -78, -RT.

Modifier -79: Unrelated procedure or service by the same physician during the postoperative period.

  • The procedure could be unrelated because it is performed in the other eye. It could also be a new problem, not related to the initial surgery of the same eye. Payment is 100% of the allowable and a new global period begins.
  • For example, a chalazion is removed from the left eye during the global period for cataract surgery on the right eye. Use code 67800, -79, -LT.

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