Published 7/1/2020
Sarah Wiskerchen, MBA, CPC

Five Tricky Modifier Questions Answered

Editor’s note: AAOS partners with KarenZupko & Associates, Inc. (KZA), on the organization’s coding education, and KZA often provides content for AAOS Now. For more information, visit www.aaos.org/membership/coding-and-reimbursement.

Modifiers are used to explain special circumstances about a service to the payer. Typically, when a modifier is not applied, the claim is denied or reimbursement is incorrectly reduced. 

Understanding how to use modifiers accurately is essential to receiving correct reimbursement. Physicians and staff regularly question whether they are using modifiers accurately and optimally. The following questions were derived from email submissions to KarenZupko & Associates, Inc. (KZA), and the subsequent answers provided by the coding education team.

1. Is it acceptable for physicians to report 20610-79 when they perform a joint injection for pain following arthroscopic knee surgery?

No. Pain management is inclusive to the global surgical package and is not separately reportable. To append a modifier 79 to a surgical procedure, the procedure is typically at a different anatomic location to support the unrelated component.

2. A patient is scheduled for manipulation under anesthesia for arthrofibrosis during the postoperative period for a total knee arthroplasty (TKA). The patient was informed prior to the TKA that he or she may need to have the manipulation done postoperatively. Is it appropriate to use modifier 58 for the manipulation because it was an anticipated service, or should we use modifier 78 because arthrofibrosis is a complication?

Modifier 58 is reported when a subsequent procedure performed during a global period is staged, planned, or more extensive than the original procedure performed to treat the condition.

In the scenario presented, although the physician discussed the potential for arthrofibrosis with the patient, the service does not meet the definition of staged, planned, or more extensive procedure than the TKA.

Report the surgical Current Procedural Terminology (CPT) code for manipulation under anesthesia with modifier 78, Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period.

3. Why would we receive a Medicare denial when reporting a major surgical procedure with a modifier 56? We only did the pre-procedure work and made the decision for surgery.

Medicare does not recognize modifier 56 (preoperative care only); instead, report the evaluation and management (E/M) for the decision for surgery. Append modifier 57 if the E/M occurs the day of or the day before the major procedure. The physician performing the surgery or fracture-related code will either report the global code or append other appropriate modifiers (e.g., modifier 54 intraoperative care only).

4. Our surgeon saw a patient in the office for a routine postoperative check during the global period of an excision of a soft-tissue tumor. During the visit, the surgeon noted that the patient had some fullness and performed a superficial incision and drainage in the office. I have the correct CPT code, but I am wondering whether I should use modifier 58 or 79? I think the correct modifier is modifier 79 because he documented a new diagnosis of “seroma.”

The reporting (or not) of this service performed in the office during the global period will depend on the payer. If the payer is Medicare or follows Medicare rules, the visit is not reportable, as this is a complication of the original surgery.

If the payer follows CPT rules and the surgeon determines this is not “typical postoperative care,” then, traditionally, no modifiers are appended. Modifier 79 is typically reserved for an “unrelated” procedure or service at a different location. The seroma is secondary to the surgical intervention; thus, if there had not been surgery, there would not be a seroma. Modifier 58 is incorrect, as this is not a planned procedure, is not more extensive, and is not part of the treatment plan. Survey your private payers to determine which modifier, if any, is required.

5. Our physician often dictates that he is performing “staged carpal tunnel surgeries” when bilateral carpal tunnel surgeries occur on different days. The second surgery occurs about eight weeks after the first surgery, within the first procedure’s global period. Are we supposed to use modifier 58 on the second surgery because it is staged?

Although the physician used the term “staged” in his operative plan, modifier 58 is not correct in this scenario. When modifier 58 is used, it is applied to subsequent procedures during a global period on the same body part. In this case, the first surgery is on the right or left carpal tunnel, and the second surgery is on the contralateral carpal tunnel—different body parts. You are correct that a modifier is required to prevent a bundling denial, but the appropriate modifier is 79 (Unrelated Procedure by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period).

Sarah Wiskerchen, MBA, CPC, is a senior consultant and coding educator with KZA, which develops and delivers the AAOS annual coding and reimbursement workshops.

Modifier definitions

  • 56: preoperative management only
  • 57: decision for surgery; an evaluation and management (E/M) service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service
  • 58: staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period