The first step in understanding how to use modifiers during the postoperative global surgical period is to review the definitions for the global surgical package. There are differences in the way the global surgical package is defined under the American Medical Association’s Current Procedural Terminology (CPT) rules and under Medicare. CPT and Medicare vary on what services may be reported during the global period and when those services may be reported.

Postoperative care definition variances
According to CPT, the surgical package includes “typical postoperative care” and the treatment of complications is not included in the surgical package.

According to Medicare, all follow-up care—including the treatment of complications—is included in the 10- or 90-day global period unless the patient is returned to an approved operative suite (operating room [OR] or approved laser, endoscopy, interventional suite, ambulatory surgical center [ASC], or intensive care unit [ICU], only if patient cannot be transferred to the OR) for the management of the complication.

Understanding these definitions and private-payer rules is critical to ensuring accurate reporting of services.

Global periods
Medicare defines global periods based on “minor” and major” procedures, as follows:

• A minor procedure has a 0- or a 10-day global period.
• A major procedure has a 90-day global period.

A 0-day procedure includes no payment for follow-up care (eg, a major joint injection).

A 10-day global period includes payment for follow-up care for 10 days after the surgical procedure (eg, complex wound repair).

A 90-day global period includes payment for all follow-up care beginning the day after surgery and for the next 90 days unless the condition requires a return to an approved operative suite (Medicare).

Postoperative surgical modifiers
While the patient is covered by a global period, the following three modifiers may be appended to surgical CPT codes to indicate that an unrelated surgical procedure is being reported:

• Modifier 58: Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period
• Modifier 78: Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period
• Modifier 79: Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period

Modifier 58 case example
Modifier 58 is appended to a subsequent staged, anticipated, or more extensive surgical procedure during the global period. This modifier typically is appended to a subsequent surgical procedure when the disease process requires additional surgical intervention for management of the entire ­condition.

Modifier 58 may be appended only during the global period and restarts the global period. When using modifier 58, the physician expects 100 percent reimbursement for the subsequent procedure. Typically the diagnosis code is the same for all subsequent surgical procedure(s) used to manage the disease process.

For example, 3 years after a total hip arthroplasty (THA), the patient is seen by the surgeon for treatment of an infected hip. The surgeon prospectively plans the management of this condition. Based on clinical data, the plan of care includes the following two stages:

• Stage One: Removal of hip prosthesis and insertion of antibiotic impregnated cement spacer. The surgeon reports codes 27091 and 11981-51 and triggers the 90-day global period. Global period modifiers are not appended to this code combination because the THA was performed 3 years earlier and the patient is not in a global period. Surgery is followed by 6 weeks of conservative management, including intravenous antiobiotics.
• Stage Two: The patient returns to the operative suite as planned and the surgeon removes the spacer and performs a THA (conversion to total hip replacement). The surgeon reports codes 27132-58 and 11982-58, 51. Modifier 58 is appended to both procedures to indicate the second stage was planned and is medically necessary to treat the disease process. Modifier 51, the multiple procedure modifier, is also appended to CPT code 11981 under CPT rules. Modifier 51 may be appended to Medicare claims based on local carrier policies. (Some local carriers accept this modifier; others do not.)

Modifier 78 case example
Unlike modifier 58, modifier 78 does not indicate a “planned, staged, or anticipated” return to the OR. Modifier 78 is appended to a subsequent procedure that requires a return to the operative suite for an unplanned condition. Most commonly this will be due to a complication at the surgical site.

Modifier 78 is only appended during the global period; it does not restart the global period and, as a result, the surgeon expects a reduction in reimbursement for the subsequent procedure. The appropriate diagnosis code related to the complication or unplanned return is linked to the surgical CPT code.

For example, a patient undergoes an open reduction internal fixation of a comminuted intra-articular distal radius fracture that also required application of an external fixator. For the first surgical procedure, the surgeon reports 25609 and 20690-51.

Six weeks later, the patient returns to the surgeon’s office for a postoperative visit complaining of pain and drainage at the pin sites of the external fixator. The surgeon assesses the situation and returns the patient to the operative suite to remove the external fixator and débride the pin sites. The surgeon decides not to replace the external fixator at this time. The surgeon reports 20694-78 for the unplanned return to the operative suite for the treatment of the wound infection (complication at the surgical site).

Modifier 79 case example
Modifier 79 is appended to an unrelated procedure during the global period. The patient is in a 10- or 90-day global period for a surgical procedure and requires a surgical intervention for an unrelated condition (typically at a different anatomic location) during that time.

Modifier 79 is only appended during the global period of an initial unrelated procedure. Because modifier 79 is unrelated, 100 percent reimbursement is expected and overlapping global periods are created.

For example, a patient is seen in the emergency department after a motor vehicle accident and is diagnosed with a displaced distal radius fracture, a displaced tibial shaft fracture, and other injuries, which are being managed by other surgical specialties. The orthopaedic surgeon performs a closed reduction of the distal radius fracture (code 25605) and, due to the patient’s condition, plans to delay the surgical management of the tibial shaft fracture for several days. The patient is admitted to the general surgery trauma service and stabilized over the next few days. The orthopaedic surgeon takes the patient to the OR on the third day as planned and reports 27759-79 for the treatment of the tibial shaft fracture. Modifier 79 is necessary because the tibial shaft fracture is unrelated to the distal radius ­fracture.

Note that modifier 24 (unrelated evaluation and management [E&M] service during the global period) should be used to report any E&M services related to the management of orthopaedic injuries not related to the distal radius fracture that are being managed by the orthopaedic surgeon. Diagnosis code linkage is critical to indicate the unrelated surgical procedure.

Next steps

• Review modifier definitions and ensure that they are ­appropriately applied, based on clinical presentation and ­treatment management.
• Avoid confusing modifiers 58, 78, and 79 due to “different diagnoses.” According to Medicare, although a complication such as infected hardware is a different diagnosis, it is not “unrelated” to the surgical ­procedure. Appending modifier 79 would be incorrect.
• Do not append modifier 58 for subsequent procedures performed in the office setting if the treatment is not part of the treatment plan. Using modifier 58 is appropriate, as necessary, for the re-application of a cast during the global period. Cast re-applications are considered surgical procedures and are part of the treatment plan.
• Conduct an internal review of services reported with modifiers 58, 78, and 79 to ensure they are being used accurately. Ensure that documentation supports the services. Remember, in 2013, the Office of the Inspector General will be focusing on appropriate use of global surgical modifiers.
• Attend an AAOS-sponsored coding course. See page 32 for a listing of course dates and locations.

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.

If you have questions about coding or want to suggest a topic for a future coding article, email aaoscomm@aaos.org