Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Modifier 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Notification Issue Date:

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

Title:

Modifier 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Policy #:

MA03.012d

Policy

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 policy applies to professional and outpatient facility claims.

Modifier 79, when used to indicate an unrelated procedure or service performed by the same professional provider or other qualified health care professional during the postoperative period of the initial procedure, is eligible for reimbursement consideration by the Company when all of the following criteria are met:

The subsequent procedure or service is performed by the same or a different professional provider or other qualified health care professional in the same provider group.
The subsequent procedure or service is performed during the postoperative period of 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
    - It occurs on a different body part, system, or organ
    - It occurs on a different day or at a different time

INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 79

It is inappropriate to report Modifier 79 in the following circumstances:

When all the requirements for the appropriate reporting of Modifier 79 are not met.
The same procedure or service, as represented by the same procedure code, is performed on the same date of service by the same or a different professional provider or other qualified health care professional a provider in the same provider group.
- In such cases, refer to the policy regarding Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional.
The procedure or service is performed after the postoperative period of the initial procedure has ended.
The procedure or service performed is related to the original procedure.

In such cases refer to the policy regarding Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

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:

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 pre-payment reviews and post-payment 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

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.

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

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.

Multiple procedures reported with Modifier 79 are subject to multiple surgery reduction guidelines.

Description

During the postoperative period of a procedure, it may be necessary for the same or different professional provider, or other qualified health care professional from the same provider group, to perform a subsequent procedure or service that is unrelated to the initial procedure or service. In such cases Modifier 79 is appended to the procedure code(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 professional 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 May 28, 2021.

Novitas Solutions, Inc. Modifier 79 Fact Sheet. 01/30/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00107559. Accessed May 28, 2021.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed May 28, 2021.

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

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA03.012d:

09/13/2021

This version of the policy becomes effective 09/13/2021. The intent of this policy remains unchanged, but the policy has been updated to clarify the Company's coverage position and coverage criteria of services reported wtih Modifier 79.

The following has been moved from a Billing Guidelines section to the Billing Requirements section of the policy:

Revisions From MA03.012c:

12/16/2019

This 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:

01/01/2018

This 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:

01/01/2017

This 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 MA03.012:

01/01/2015

This is a new policy.

Version Effective Date:

9/13/2021

Version Issued Date: