Home Town Health - August Jenan Custer CPC, CCS, CDIP AHIMA Approved ICD-10-CM/PCS Trainer and Ambassador Director of Coding Healthcare Coding and Consulting Services (HCCS)

Agenda Multiple Modifier Usage: Post Operative Services - 58, - 78, -79 AHA Coding Clinics 1Q/ 2Q 2016

Home Town Health - August Multiple Modifier Usage: Post Operative Services -78 -79 -58

Home Town Health - August Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Home Town Health - August Modifier 58 • A procedure performed by the original surgeon or Provider • A follow-up surgery more extensive than the original procedure • A therapy following a diagnostic surgical procedure

Home Town Health - August Modifier 58 What story does modifier -58 paint? When not to use -58 modifier Reminder: Check for additional FI Guidance

Home Town Health - August Appropriate use of modifier -58 • To report a secondary procedure that was staged or planned at the time of the original procedure • When the secondary procedure is more extensive than the original procedure • For therapeutic services following a diagnostic procedure • When performing a second or related procedure during the postoperative period • Bill modifier -58 with the subsequent performed procedure

Home Town Health - August Inappropriate use of modifier -58 • Appending the modifier to services listed in CPT as multiple sessions (e.g., 67208, destruction of localized lesion of retina, one or more sessions) • For a service that is treating a complication from the original surgery (see modifier -78) • Unrelated procedures

Home Town Health - August Coding Scenario Modifier -58 A mastectomy on a patient was performed, during the postoperative global period inserted a permanent prosthesis

Home Town Health - August Coding Scenario Answer Modifier -58 The surgeon would report the code for the permanent prosthesis insertion with the -58 modifier to indicate that this service was related to the mastectomy (staged to occur at a time after the initial surgery). CPT Assistant, Winter 1993 Page: 27

Home Town Health - Reporting modifier -78 Return to the operating room for a related procedure during the postoperative period

Home Town Health - August Does your coding situation qualify to use the -78 Modifier? • Relates to the first procedure • Requires the use of an operating room

Home Town Health - Appropriate use of modifier -78 • To identify a related procedure requiring a return trip to the OR on the same day as another surgery • Use modifier -78 on the second performed procedure (i.e., performed during the return trip) • To treat the patient for complications resulting from the original surgery (it’s important to note the CPT definition for the modifier does not limit its use to treatment for complications) • When the procedure code used to describe a service for treatment of complications is the same as the procedure code used in the original procedure, modifier -78 is still the correct modifier to use

Home Town Health - August Coding Scenario Modifier -78 A partial colectomy was performed in the hospital on March 1. The postoperative period for this procedure is 90 days. On March 15, the patient was returned to the operating room for treatment of partial dehiscence of the incision with secondary suturing of the abdominal wall. The secondary suturing was related to the original surgery.

Home Town Health - Coding Scenario Modifier -78 CPT code reported for the first procedure: 44140 CPT code and modifier reported for the second procedure: 49900-78 CPT Assistant, September 2010 Page: 6, 7, 11

Home Town Health - August Reporting modifier -79 Modifier -79 is used to describe an completely unrelated procedure or service by the same physician during the postoperative period.

Home Town Health - The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure

Home Town Health - August Coding Scenario Modifier -79 A 68-year-old woman had an unfortunate landing while bicycling and sustained a mildly non-displaced closed fracture of the right distal ulna. Because of the patient's condition and the nature of the injury, closed manipulation treatment was performed in the operating emergency room, with placement of a long-arm plaster splint. The patient was discharged. Later in the day, the patient returned to the emergency department after experiencing nasal bleeding with clots. After unsuccessful pressure packing insertion and the use of local vasoconstrictors, the patient was returned to the operating room, where bleeding was controlled by repair of a posterior arterial hemorrhage with cautery.

CPT codes(s) and modifier reported: 25535, 30905-79 (same date). Home Town Health - Coding Scenario Answer Modifier -79 CPT codes(s) and modifier reported: 25535, 30905-79 (same date). CPT Assistant, September 2010 Page: 6, 7, 11

Home Town Health - August Coding Clinic Updates

Home Town Health - August Coding Clinic, Second Quarter ICD-10 2016 Page:9 Effective with discharges: May 27, 2016 Question: When coding comparative/contrasting secondary diagnoses in the hospital inpatient setting, which guideline applies?

Home Town Health - August Answer: Coders in the hospital inpatient setting should apply the guideline for uncertain diagnosis, when coding comparative/contrasting secondary diagnoses. The Official Guidelines for Coding and Reporting, Uncertain Diagnosis state, "If the diagnosis documented at the time of discharge is qualified as 'probable', 'suspected', 'likely', 'questionable', 'possible', or 'still to be ruled out', or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis."

Home Town Health - Coding Clinic, Second Quarter ICD-10 2016 Pages: 8-9 Effective with discharges: May 27, 2016 Question: A cocaine abuser is diagnosed as overdosing on crack cocaine and is admitted to the hospital. This is clearly a poisoning, but what is the appropriate "intent" for the poisoning code: accidental (unintentional) or undetermined? Is there a "default intent" for the poisoning codes?

Home Town Health - August Answer: In ICD-10-CM, the default for the intent for poisonings is accidental. Assign code T40.5X1A, Poisoning by cocaine, accidental (unintentional), initial encounter, for the crack cocaine overdose. Rational

Home Town Health - Coding Clinic, First Quarter ICD-10 2016 Page: 17 Effective with discharges: March 18, 2016 Question: The instructional note at category M50, Cervical disc disorders states, "Code to the most superior level of disorder." Coders at our facility are trying to interpret this instruction for assigning codes for cervical disc disorders. Does this directive apply only to adjacent levels? If several regions are affected, involving different levels (e.g., C3-C4 and C5-C6), is the code for only the most superior level assigned or can both levels be coded?

Home Town Health - August

Home Town Health – August

Home Town Health - August Answer: The intent of the note is to code each disorder at the highest (most superior) level. Each fourth digit subcategory describes a unique disorder, so within each subcategory, code to the highest level. For example, if several regions are affected (e.g., C3-C4 and C5-C6) that are classified to the same subcategory (e.g., M50.0), assign code M50.01, Cervical disc disorder with myelopathy, high cervical region, as C3-C4 is the most superior level.

Home Town Health - Multiple Modifier Usage: Post Operative Services - 58, - 78, -79 AHA Coding Clinics 1 Q/ 2Q 2016

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