Author: Kimberly Mansingh

At the end of each year, there is always a rush to learn about the CPT updates that will go into effect on January 1^st. While it is important to get up to speed on what has changed (which is why we have created training modules to bring you that new information), the New Year also makes me step back and reflect on old concepts as well. It is a great time to ensure you have your latest coding resources downloaded and to renew your understanding of long-established codes as well.

With that in mind, today’s article will focus on three modifiers that are not new, but are critical for all surgery coders to understand: modifiers 58, 78, and 79. All three modifiers may be reported when a procedure is performed during the global period of a prior procedure. Let’s start with a look at how these modifiers are defined and some helpful tips that can ensure you use them appropriately.

• Modifier 58: Modifier 58 is often thought of as the “staged” modifier. While that is partially correct, modifier 58 has more to its definition:
  • Use modifier 58 when a procedure performed during the global period was planned at the time of the initial procedure (e.g. a colectomy is performed with the abdomen left open intentionally, and then the patient is brought back to the operating room for planned closure of the abdomen two days later) –or-
  • When the procedure performed in the global period is more extensive than the initial procedure (e.g., a breast mass is excised, but when the pathology comes back as cancer, a lumpectomy is performed in the global period) –or-
  • For therapy following a diagnostic surgical procedure (e.g., a patient undergoes open thrombectomy and then thrombolysis therapy is started a few days to resolve residual clots during the global period)

• Modifier 78: Modifier 78 is reported for an unplanned return to the operating room when the procedure performed during the global period is related to the original procedure:
  • Use modifier 78 when treatment of a complication of the initial surgery results in a return trip to the operating room (e.g., a surgeon performs an open aortic valve replacement and then has to take the patient back to the operating room 2 days later to control mediastinal bleeding) –or-
  • When the procedure performed in a global period is related to the original procedure and was not planned at the time of the initial surgery (many examples may apply but most often you will see treatment of complications) –or-
  • When the same CPT code is reported for treatment of complications in the global period of a prior procedure (e.g., the surgeon performs ORIF of the radius, but the patient suffers a re-fracture due to her osteoporosis and a fall at home so ORIF is repeated in the global period)

• Modifier 79: Modifier 79 is reported for an unrelated procedure performed in the global period of the original procedure:
  • Use modifier 79 when a completely unrelated procedure is performed in the global period of the original surgery (e.g., initial surgery is ORIF for hip fracture and second surgery is ORIF for a humerus fracture) – or-
  • When the same CPT code is reported for the surgery performed in the global period of the original procedure, but does not represent the same procedure performed at the same anatomic site (e.g., cataract surgery on the left followed by cataract surgery on the right in the global period)

Here are some additional tips for using global modifiers correctly:

• Global modifiers are used when the patient has a second surgery in the global period with the same surgeon or a surgeon in the same specialty/group practice:
  • Do not apply global modifiers if the patient is in a global with a surgeon outside your practice.
  • Do not apply global modifiers if the patient has a procedure with a surgeon in a different specialty in the same group practice (e.g., patient had surgery with orthopedics which put them in a global but then has a procedure with cardiology in the global period)
• Modifier 78 specifically requires a return to the operating room:
  • An operating room may be formally labeled an operating room or could be an equivalent space (e.g., procedure room, cath lab)
  • For Medicare and payers following Medicare’s guidelines, do not code the treatment of complications that do not require a return to the operating room separately (e.g., incision and drainage of a wound infection in the office). Check the policies for your private commercial carriers to see if they follow Medicare or have their own policy.
• Modifiers 79 and 58 may be reported for procedures that occur in the operating room during a global period, or they may be reported with unrelated or staged procedures/therapy that occur outside of the operating room, but still in the global period.
• Each CPT code is assigned a global indicator on the Medicare Physician Fee Schedule: 000, 010, 090, MMM,XXX, YYY, ZZZ:
  • The first three indicators refer to the number of global days for that procedure (i.e., 010 is assigned to a code with 10 global days)
  • MMM indicates a maternity code, and the usual global period does not apply
  • XXX indicates that the global concept does not apply
  • YYY indicates a code where the Medicare contractor determines how many global days apply
  • ZZZ indicates a code that is related to another service and always included in the global period (e.g., add on code)
  • Why does this matter? Many Medicare contractors state that you should not apply modifiers 58, 78, or 79 to a code with an XXX or ZZZ global indicator because these codes will be allowed without any global modifier. Some payers may just view the modifier as not required, but others may consider it an error and reject a claim if you apply the global modifier to a code with those indicators. So be aware of that guidance and check your global indicators when assigning these modifiers

Finally, a great place to get additional information about how to use global modifiers correctly is in fact sheets published by your local Medicare Administrative Contractor (MAC). To find these sheets, you can Google “modifier __ (e.g., 78) fact sheet,” and you should get search results right at the top for fact sheets from your MAC. Here are a couple of examples from Novitas and Noridian:

https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144546

https://med.noridianmedicare.com/web/jeb/topics/modifiers/78

I hope that is a helpful refresher for you on global surgery modifiers. One of the great things about coding is that no matter how long you have been in the field, there is always more to learn. Happy New Year, and thank you for letting me be part of your coding journey!