Global Billing: Document ‘Unrelated’ for Modifier 79 Services

Posted on 07. Jan, 2010 by Editor in Hot Coding Topics

MACs are looking for ‘red flags’ to halt additional global period pay

Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.

After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt for modifier 79 abuse. Implement our expert tips below to keep your 79 claims clean.

Obey Global Package Model

The starting point for clean modifier 79 claims is not breaching the global surgical billing concept. Once you understand the global package rules, you’ll know when you have an exception that warrants an additional claim with an appropriate modifier.

Know what’s included: The global package includes the preoperative visit the day before surgery, intraoperative services, postsurgical complications, and postoperative visits during the global period. It also includes post-surgical pain management services by the surgeon, and miscellaneous services such as dressing changes, suture removal, staples, etc., according to Donna Pisani, provider outreach and education consultant with National Government Services (NGS) during a global surgery conference call. NGS is a Medicare payer in 25 states.

Choose 79 for Distinct Procedure During Global Period

If your surgeon performs a service during the global period that the “package” doesn’t include, you can bill separately for the additional procedure — but you’ll have to use a modifier.

Key to 79: You’ll know that 79 is the correct modifier if the second procedure is for an unrelated condition during the global period of the first surgery. In other words, if the same surgeon must perform a separate, unrelated procedure for an unexpected medical condition during theglobal period of a previous procedure, you should append modifier 79 to the subsequent procedural code(s).

Tip: “If the second procedure takes place on a different body part, 79 is usually the correct modifier,” says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio.

Another clue that you should use 79 is if the surgeon links a second...

Tags: 19301, audit, bundling, global, MAC, modifier 58, modifier 78, modifier 79, NGS, return to operating room, staged procedure, unrelated procedure