Published 6/1/2008
Mary LeGrand, RN, MA, CCS-P CPC

Additional modifier changes for 2008

Last month, we reviewed the changes for modifiers 22, 25, and 76 that went into effect in 2008. This month, we’ll examine the changes for modifiers 51, 58, 59, and 78.

Modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code, or to indicate a special circumstance when reporting a service. During the perioperative global period, modifiers are critical to ensuring that the provider receives reimbursement for services that are unrelated to the primary procedure, as well as for staged procedures, multiple procedures, assistant surgeon or co-surgeon services, and evaluation and management (E&M) services. Modifiers may be appended to E&M services, surgical CPT codes, diagnostic tests, laboratory tests, and services from the “Medicine” section of the CPT Manual.

Changes for modifier 51
The definition for modifier 51—multiple procedures—changed in 2008. When multiple procedures—other than E&M services, physical medicine and rehabilitation services, or provisions of supplies (eg, vaccines)—are performed at the same session by the same provider, the additional procedure(s) or services(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Do not append modifier 51 to designated add-on codes, identified in CPT by a “+” and listed in Appendix D. The primary procedure or service is reported as listed.

Do not append modifier 51 to CPT codes exempt from modifier 51. These are identified by the symbol “” and are also listed in Appendix E.

Changes for modifier 58
The definition of modifier 58—staged or related procedure or service by the same physician during the postoperative period—also changed in 2008. The new definition follows:

“It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure:

“See modifier 78 for treatment of a problem that requires a return to the operating or procedure room (eg, unanticipated clinical condition).”

For example, on May 1, a surgeon sees a patient who has a pilon fracture involving the tibia and fibula. Because the patient’s limb is too swollen to permit an immediate open reduction with internal fixation (ORIF), the surgeon manipulates the fracture to restore limb length and improve fracture alignment. The surgeon also applies a uniplane external fixator to maintain the position and avoid use of a cast or splint. On May 5, when the swelling has subsided, the physician takes the patient to the operating room for ORIF of the pilon fracture.

For the May 1 patient visit, the physician would submit CPT codes 27825 (closed treatment of fracture of weight bearing articular portion of distal tibia [eg pilon or tibial plafond], with or without anesthesia; with skeletal traction and/or requiring manipulation) and CPT code 20690-51 (application of a uniplane [pins or wires in one plane], unilateral, external fixation system). On May 8, the surgeon dictates ORIF of pilon fracture and removal of external fixator and reports CPT code 27828-58 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [eg, pilon or tibial plafond], with internal fixation, when performed; of both tibia and fibula) and CPT code 20694-58,51 (Removal, under anesthesia, of external fixation system).

NOTE: Consultation or initial hospital care on May 1 is not addressed in this example. If either E&M service is performed, the appropriate E&M code should be reported. Modifier 57 should be used if the E&M service occurred on the day of or the day before placement of the external fixator.

The physician should submit the full fee for each procedure. Expected reimbursement is 100 percent for 27825 on the May 1 visit and 100 percent for the ORIF on May 8. Payors will apply a multiple procedure reduction for application and removal of the external fixator (codes 20690 and 20694) on both days.

Changes for modifier 59
Modifier 59—distinct procedural service—underwent a definition clarification. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E&M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E&M services, that are not normally reported together but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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. When another already established modifier is appropriate, however, it should be used rather than modifier 59. Modifier 59 should be used only if no more descriptive modifier is available; it should not be appended to an E&M service. Modifier 25 should be used to report a separate and distinct E&M service with a non-E&M service performed on the same date.

For example, during a follow-up visit, the physician injects both the right shoulder and the right knee because the patient is in pain. The physician reports CPT code 20610 (arthrocentesis, aspiration and/or injection; major joint or bursa [eg, shoulder, hip, knee joint, subacromial bursa]) for the right knee injection, and 20610-59 for the right shoulder injection.

Drugs would be reported as appropriate. No other modifier is appropriate to differentiate the anatomic location, but each procedure should be linked to the appropriate diagnosis.

Using modifier 78
Modifier 78 indicates an unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period. If another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure), and the procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.

For example, 2 weeks after a posterolateral fusion, the patient returns to the OR for incision and drainage of a subfascial lumbar spine infection around the hardware. The physician would report 22015-78 (incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral).

Source: CPT Changes: Insiders Edition 2000-2008.

Mary LeGrand, RN, MA, CCS-P CPC, is a consultant with KarenZupko & Associates. The information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org