Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
Policy #:MA03.012c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

Modifier 79 (unrelated procedure or service by the same physician or other qualified health care professional during the post-operative period) must be reported in the following circumstances:
  • The subsequent procedure or service is performed by the same provider or a provider in the same provider group.
  • The subsequent procedure or service is performed during the postoperative period of the original procedure.
  • The subsequent procedure or service is unrelated to the initial procedure as evidenced by all of the following:
    • The subsequent procedure or service is not a treatment for a complication of the initial procedure or service.
    • The subsequent procedure or service is not a repeat of the initial procedure (same procedure, on the same body part, system, or organ).
    • The diagnosis reported for the subsequent procedure or service is one of the following:
      • Different from the diagnosis reported for the initial procedure
      • Similar to or the same as the diagnosis reported for the initial procedure and its cause is different from the initial procedure; it occurs on a different body part; or it occurs at a different time/date if any one or more of the following applies to the subsequent procedure or service:
        • It is caused by different events or external causes
        • It occurs on a different body part, system, or organ
        • It occurs on a different day or at a different time
  • Supporting medical necessity documentation is maintained in the medical record describing the circumstances precipitating the performance of the subsequent procedure or service.
    • The member's medical records must be available to the Company upon request.

INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 79

It is inappropriate to report Modifier 79 with a procedure code in the following situations:
  • All the requirements for the appropriate reporting of Modifier 79 are not met.
  • The same procedure, as represented by the same procedure code, is performed on the same date of service by the same professional provider or a professional provider in the same provider group.
    • In such cases, refer to the Cross References section for a link to the policy that addresses Modifier 76.
  • The procedure is performed after the postoperative period of the initial procedure has ended.
  • The procedure performed is related to the original procedure.
  • The original procedure code does not have a postoperative period.

It is not appropriate to append both modifier 79 and modifier 78 (return to the operating room [OR] for a related procedure during the postoperative period) to the same procedure code.

ADDITIONAL POLICY INFORMATION

The following applies when claims are received with procedure codes appended with Modifier 79 and such services meet all policy requirements noted above:
  • The postoperative period of the initial procedure remains intact.
  • Procedure codes appended with modifier 79 are not subject to the Global Surgery/Postoperative Period rules applied to the initial procedure.
  • A new, independent postoperative period is applied to the subsequent procedure.
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Policy Guidelines

This policy is consistent with Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.

In order to determine if it is appropriate to report a procedure code with modifier 79, the provider should verify the number of days representing the postoperative period applied to the initial procedure.

The physician or other qualified health care professional should report the diagnosis code that provides the highest degree of specificity.

If multiple unrelated procedures are subsequently performed by the same professional provider or other qualified health care professional, append modifier 79 to each of the corresponding procedure codes.

Description

During the postoperative period of a procedure, it may be necessary for the same provider, or a provider from the same group practice, to perform an additional procedure or service that is both unrelated to the initial procedure or service and requires a return to the operating room (OR). Modifier 79 is appended to the procedure code(s) representing the subsequent procedure(s) or service(s) to indicate that the procedure(s) or service(s) performed is/are unrelated to the initial procedure.


As used in this policy, postoperative period refers to the period of time following a surgical or other invasive procedure during which reimbursement for certain procedures or services is included in the global surgical reimbursement to the provider or provider group.

As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.


References

Centers for Medicare and Medicaid Services (CMS). MLN Booklet: Global Surgery Booklet. [CMS Web site.] September 2018. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Accessed October 14, 2019.

Novitas Solutions, Inc. Modifier 79 Fact Sheet. 01/30/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00107559. Accessed October 14, 2019.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed October 14, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifier:

79 Unrelated procedure or service by the same physician during the postoperative period



Coding and Billing Requirements


Cross References

Related Documents




Policy History

REVISIONS FROM MA03.012c
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of modifier 79.

REVISIONS FROM MA03.012b
01/01/2018This version of the policy will become effective 01/01/2018.

The policy has been reissued to communicate the removal of the following CPT codes: 0051T, 0052T, 0053T, 0293T, 0294T, 0299T, 0300T, and 0301T. There are no changes to the coverage position or the criteria.

REVISIONS FROM MA03.012a
01/01/2017This policy has been identified for the CPT code update.

The following CPT codes have been removed from the policy:
0019T, 0169T, 0171T, 0172T, 0281T, 0282T, 0283T, 0284T, 0285T, 0288T and 0289T

REVISIONS FROM MA03.012a
01/01/2015This is a new policy.




Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A