Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Policy #:03.00.28l

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The Company has established the following requirements to report Modifier 79 with the procedure codes listed in the Coding Table:
  • 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 applied to the initial 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 (eg, a fall from chair and a bicycle accident)
        • It occurs on a different body part (eg, pathological fractures of both a wrist and an ankle), system, or organ
        • It occurs at a different time (eg, on a different day)
  • 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.

ADDITIONAL POLICY INFORMATION

The following rules are applied when medical claims are received with procedure codes appended with modifier 79 and such services meet all policy requirements:
  • 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.
  • An independent postoperative period is applied to the subsequent procedure.

Guidelines

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

Additional claims and reporting information:
  • 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 should report the diagnosis code that provides the highest degree of specificity, using the fourth and fifth digits where applicable.
  • If multiple procedures are subsequently performed, append modifier 79 to each of the corresponding procedure codes
    • Multiple surgical procedures appended with modifier 79 are subject to standard multiple surgical reduction guidelines.
  • It is not appropriate to report both modifier 79 and modifier 78 (return to the operating room [OR] for a related procedure during the postoperative period) appended to the same procedure code.
  • Medical records, notes, or other supporting documentation should not be submitted unless specifically required and/or requested by the Company.

This policy is applicable to all products.

Description

During the postoperative period of a procedure, it may be necessary for the same physician (or a physician 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 representing the subsequent procedure or service to indicate that the procedure or service performed is 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 reimbursement to the provider or provider group.
References


Beebe M, ed. Principles of CPT® Coding. 4th ed. Chicago, IL: American Medical Association Press; 2005.

Beebe M, Dalton JA, Espronceda, M. et al, eds. CPT® 2007 Professional Edition: Current Procedural Terminology. 4th ed. Chicago, IL: American Medical Association Press; 2006.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub. 100-04 Medicare claims processing. Transmittal 126. [CMS Web site]. 03/26/04. Available at: http://www.cms.hhs.gov/transmittals/Downloads/R126CP.pdf. Accessed April 18, 2007.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 - Physicians/nonphysician practitioners. §40.1B Services not included in the global surgical package. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed April 18, 2007.

General Assembly of Pennsylvania. Senate Bill 91; Article XXI: Quality health care accountability and protection. §2102: Definitions [Pennsylvania General Assembly Web site]. 01/21/97. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=1997&sessInd=0&billBody=S&billTyp=B&billNbr=0091&pn=2082. Accessed March 13, 2007.

Hall DC, Orme N, eds. 2007 Ingenix University: Understanding Modifiers. Salt Lake City, UT: Ingenix, Inc.; 2006.

Highmark Medicare Services. Medicare Part B Reference Manual. Appendix B, Modifiers. 79: Unrelated procedure by the same physician during the postoperative period. [Highmark Medicare Services Web site]. January, 2005. Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/appendix-b.pdf. Accessed April 18, 2007.

Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 22: Global surgery and related issues. [Highmark Medicare Services Web site]. January, 2006. Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/chapter22.pdf. Accessed March 13, 2007.




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)

THE FOLLOWING ARE CODES AND CODE RANGES TO WHICH MODIFIER 79 MAY BE APPENDED:

0003T, 0008T, 0020T, 0021T, 0031T, 0033T, 0034T, 0035T, 0036T, 0037T, 0043T, 0046T, 0047T, 0048T, 0049T, 0050T, 0060T, 0062T, 0063T, 0072T, 0075T, 0076T, 0077T, 0078T, 0079T, 0084T, 0124T, 0163T, 0164T, 0165T, 0170T, 0171T, 0184T, 0186T, 0190T, 0191T, 0192T, 0205T, 0206T, 0207T, 0208T, 0209T, 0210T, 0211T, 0212T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 0276T, 0277T, 0278T, 0290T, 0295T, 0296T, 0297T, 0298T, 0347T, 0348T, 0349T, 0350T, 0351T, 0352T, 0353T, 0354T, 0355T, 0356T, 0358T, 10021- 69990, 90291-91299, 92015-99091, 99170-99199, 99500-99602


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)

THE FOLLOWING ARE CODES TO WHICH MODIFIER 79 MAY BE APPENDED:

A9527, A9568, D3222, G0002, G0159, G0160, G0169, G0170, G0171, G0173, G0183, G0184, G0185, G0186, G0187, G0251, G0259, G0260, G0267, G0268, G0269, G0272, G0279, G0281, G0282, G0283, G0289, G0290, G0291, G0295, G0298, G0299, G0339, G0340, G0341, G0342, G0343, G0392, G0393, G0412, G0413, G0414, G0415, G0448, G8524, M0076, M0301, Q0068, S0400, S0800, S0810, S0812, S2050, S2052, S2053, S2054, S2055, S2060, S2061, S2065, S2066, S2067, S2070, S2080, S2083, S2102, S2103, S2107, S2109, S2112, S2115, S2118, S2120, S2140, S2142, S2150, S2152, S2180, S2202, S2204, S2205, S2206, S2207, S2208, S2209, S2210, S2213, S2220, S2225, S2230, S2235, S2250, S2300, S2340, S2341, S2342, S2348, S2350, S2351, S2360



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


Policy History

REVISION FROM 03.00.28l
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.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2018
Version Issued Date: 01/10/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.