Hello,
Can someone give me some more direction on the use of modifier 78? I have a provider that is trying to bill a 78 on seroma aspirations that are arising from breast procedures done in the OR. The seroma aspirations are done in the office. I consider this a complication of the surgery and feel that the aspiration should be covered under the global period.
First, does it matter if the main procedure to start the global period was done in OR and the complication is being taken care of in the office?
Second, does anyone think that these should be billed separately?
Third, if you have any documentation to support your opinion could you please provide your resource as I know my provider will want to see it in writing.
Thanks in advance for any help.
Medicare's language clearly states Modifier 78 is for post-operative complications requiring a trip to the OR. (Commercial payers could vary. You'd have to research whether your contracted Commercial payers follow Medicare's definition or whether they define the global surgical package differently.)
Medicare's language is in the Medicare Claims Processing Manual and is also referenced in the Medicare Learning Network booklet on Global Surgery.
MLN Global Surgery booklet link:
https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
Medicare Claims Processing Manual also details the Components of a Global Surgery Package on page 68 of this PDF:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
A. Components of a Global Surgical Package B3-15011, B3-4820-4831
A/B MACs (B) apply the national definition of a global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.
The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services (CPT codes 99291 and 99292) are payable separately in some situations. (See section 30.6.12.7 of this chapter forfurther discussion of critical care visits unrelated to the procedure with a global surgicalperiod.)
• Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
• Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;
•
Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;
• Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
• Postsurgical Pain Management - By the surgeon;
• Supplies - Except for those identified as exclusions; and
• Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains,casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Page 69 of the same PDF lists
Services Not Included in the Global Surgical Package. I won't paste the whole thing, but here's the portion of that section relating to postoperative complications that would not be considered part of the Global Surgical Package:
•
Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit(unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);