Choose the correct modifier for surgical procedures
Surgical procedures don’t always go as planned. A surgery might be postponed before the patient even reaches the operating room or a physician may need to take a patient back to the OR after surgery. As a result, the procedure no longer matches the code and you need to convey that information using a modifier.
But which modifier should you use? The 2011 CPT® Manual contains 13 Level 1 modifiers specifically for outpatient hospital coding, including eight that can relate to surgical procedures. Selecting the appropriate modifier requires careful reading of the medical record and operative report to determine exactly what took place during the procedure and where the patient was.
Let’s start by considering two modifiers that apply to uncompleted procedures. Documentation is critical when using these modifiers, says Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president/CEO and principal consultant for SLG, Inc., in Raleigh, NC.
Specifically, look for when and why the provider discontinued the procedure.
“It is often difficult to determine wheels-in, wheels-out time of the OR, let alone the reason and exact timing of a discontinued procedure,” Goodman says.
That little tidbit of information may seem trivial at the time, but plays a large part in determining which modifier you use and whether you should code a surgical procedure at all. “If the procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, you should not report a procedure,” Goodman says.
Patients don’t always make it into the OR or even the prep area before the physician decides to discontinue the procedure. If the patient is prepped for surgery, is wheeled into the procedure room, and the physician decides not to continue with the procedure, append modifier -73 (discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) to the procedure code.
Before appending the modifier, make sure the patient was actually being prepped for surgery and was taken into the surgery waiting area. If the physician decided to cancel the procedure before the patient was prepped or before the patient was moved from the waiting area, do not report a procedure code. In those cases, coders may be able to report an evaluation and management (E/M) code, depending on what services the physician or qualified nonphysician practitioner provided.
For example, surgical staff members prepped a 57-year-old male Medicare patient for a repair of a recurrent femoral hernia and took him to the OR. Before the anesthesiologist administered anesthesia, the patient complained of chest pain. The physician hooked the patient to a cardiac monitor, which revealed ST-segment elevation. The physician cancelled the procedure. In this case, report CPT code 49555-73 for the hernia repair.
If the patient had complained of chest pain in the waiting room before the surgical staff prepped him for the OR and the surgeon decided to abort the procedure, you would not report the repair code. The same holds true if the patient decides not to have the procedure.
On the other hand, a patient might actually be in the OR and the provider may administer anesthesia before deciding to cancel the procedure. Perhaps the patient had a bad reaction to the anesthesia or another medical complication and the surgeon stops the procedure.
If anesthesia is administered and then the procedure is stopped for a medical reason, append modifier -74 (discontinued outpatient hospital/ASC procedure after the administration of anesthesia) to the procedure code.
For example, our 57-year-old patient above receives anesthesia and the surgeon begins the procedure. The anesthesiologist notices the patient is experiencing ventricular fibrillation and the surgical team initiates defibrillation procedures. They control the arrhythmia and the surgeon terminates the procedure. In this case, report code 49555-74.
Remember that Medicare defines anesthesia to include local and regional blocks, moderate sedation, deep sedation/analgesia, and general anesthesia.
“In some cases you may need to use a CPT or HCPCS code that classifies the extent of the procedure performed, when such a code is available, instead of reporting the intended procedure,” Goodman says. If the surgeon planned to perform multiple procedures, but only completes one of them, only code the completed procedure. Do not report procedures that the surgeon planned but did not perform. If the surgeon did not complete any of the procedures, report the first planned procedure with either modifier -73 or -74 as appropriate.
Consider this case. A surgeon schedules a 65-year-old male Medicare patient for an upper gastrointestinal (GI) endoscopy and a colonoscopy. The surgeon completed the endoscopy, but the patient’s blood pressure began to fall sharply and the surgeon decided to end the operative session.
Report only code 43235 for the diagnostic upper GI endoscopy. Do not report a code for the colonoscopy since the surgeon had not started the procedure.
So now let’s look at some modifiers that are used when a practitioner takes a patient back to the OR after surgery.
When a surgeon has to take a patient back to the operating room to perform the same procedure, append modifier -76 (repeat procedure or service by the same physician or other qualified healthcare professional) to the second procedure. The Medicare Hospital Manual, Section 442.9, states:
Use this modifier to indicate that a procedure or service was repeated in a separate operative session on the same day. Report the procedure once and then report it again with modifier -76 added (two line items on the bill).
“You can’t get hung up on the reference to operative,” says Lolita M. Jones, RHIA, CCS, an AHIMA-certified ICD-10 trainer and principal of Lolita M. Jones Consulting in Fort Washington, MD. “We’re really talking about a true separate and distinct session, but it may not be an operative procedure.”
For example, if a patient undergoes three respiratory studies, report the respiratory study code one time. On the second line, report that same respiratory code with a modifier -76 with two in the units of service field, Jones says.
Most of the cases that require modifier -76 will be nonsurgical cases, Jones says. However, because more patients are being seen as outpatients, you may start seeing more cases on the surgical side that require modifier -76.
CMS does include an exception to reporting guidelines for ambulatory surgery procedures. For surgical procedures, do not use the units of service field to indicate the provider performed the procedure multiple times. Instead, report the procedure code once without a modifier, then repeat the code with modifier -76 for each additional time the provider performed the procedure.
For example, a patient receives an epidural injection of the lumbosacral spine. In the recovery room, the patient complained of continued pain, so the surgeon decided to return the patient to the OR to repeat the procedure. For this case, you should code 62311 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance(s) [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) and 62311-76.
“You want to be very sensitive to the reporting structure because you don’t want the claim to be kicked back because you used the inappropriate billing mechanism based on the type of procedure it is,” Jones says.
In some cases a different physician may repeat the procedure. In these instances, append modifier -77 (repeat procedure or service by another physician or other qualified healthcare professional). The Medicare Hospital Manual, Section 442.9, guidelines are very similar to those for modifier -76, including the exception for ASCs, Jones says.
In fact, Section 442.9 states that both modifiers -76 and -77 may be reported for services ordered by physicians but performed by technicians. If a technician performed the procedure (e.g., electrocardiograms [EKG]) or a therapist performed the procedure (e.g., respiratory therapy), refer to the ordering physician’s notes to determine the appropriate modifier assignment.If you are dealing with a service that was repeated and it was not carried out by a physician, then look to see whether the same physician ordered the repeat procedures or services, Jones says. If the same physician ordered the repeat services, use modifier -76. If a different physician ordered the repeat service or procedure, append modifier -77.
The AMA also revised both modifiers to include the phrase “or other qualified healthcare professional.”
To use modifiers -76 and -77, the procedure must be exactly the same. If the provider performs different procedures or the same procedure in a different area, such as an epidural injection in two different locations, do not append modifier -76 or -77.
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at firstname.lastname@example.org.