Understand Modifier 79 With Examples

Avoid Common Mistakes with Modifier 79: Top 10 Tips

Pairing CPT codes with ICD-10 codes may appear straightforward, but there are always nuances and exceptions to consider. Physicians often face related services, global periods, and other complicating factors. Modifiers play a crucial role in clarifying these situations, potentially ensuring payment that might otherwise be denied. However, incorrect modifier usage can lead to claim denials, just as omitting a necessary modifier can. It is essential to fully grasp the implications of each modifier.

In this series of blogs, we highlight 10 of the most frequently misused modifiers. Our goal is to increase your awareness of the issues associated with them, explain why they are often problematic, and guide you on their proper usage.

Understanding Modifier 79: Key Insights

According to CPT, Modifier 79 is designated for an "unrelated procedure or service by the same physician during the postoperative period." This modifier is specifically for instances where the new care is entirely separate from the surgery that initiated the current global period.

Modifier 79 is informational, meaning no additional documentation needs to be submitted with the claim. However, supporting documentation must be kept in the patient's medical record to verify that the procedures are unrelated. Importantly, using Modifier 79 restarts the global period, initiating a new postoperative period when the unrelated procedure is billed.

Common Misuse:

Modifier 79 is often confused with similar modifiers, including:

• Modifier 76: Repeat procedure or service by the same physician or other qualified healthcare professionals.
• Modifier 78: Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following the initial procedure for a related procedure during the postoperative period.
• Modifier 58: Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period.

Proper Use of Modifier 79

Modifier 79 is used to indicate an unrelated procedure performed by the same physician during the postoperative period of the original surgery. When the procedure is related to the original surgery or is a staged (anticipated) surgery, it falls under the global period and should not use Modifier 79. 

When to Use Modifier 79:

Modifier 79 should be used when a patient returns for a second procedure during the global (postoperative) period of the first procedure, and the reason for the second procedure is completely unrelated to the first. It is not to be used for identical procedures performed on the same day at the same anatomical site.

How to Distinguish Between Modifiers:

• Modifier 76: Use when the same physician performs an identical procedure on the same day but at different anatomical sites.
• Modifier 78: Use for an unplanned return to the operating room for a related procedure due to complications from the initial surgery.
• Modifier 58: Use for a staged or related procedure that is planned or anticipated as a necessary step following the initial surgery.

Example 1:

Dr. Smith performed cataract surgery on Mr. Johnson's right eye on August 15, 2023, and billed it as 66982-RT. A month later, on September 15, 2023, Dr. Smith conducted cataract surgery on Mr. Johnson's left eye. Since this second procedure took place within the 90-day postoperative period of the first surgery, Dr. Smith should report the second surgery as 66982-79LT. The use of Modifier 79 is appropriate here because the second surgery is unrelated, being performed on a different eye.

Example 2:

A 25-year-old woman suffers a broken femur from a fall, and the orthopedist performs an open reduction to repair the fracture. Two weeks later, while descending stairs with her new cast, she trips and breaks her radius. The same orthopedist performs another open reduction for the new fracture during the global period of the initial procedure.

Since the two procedures are unrelated, you should report 27506 (Open treatment of femoral shaft fracture with plate/screws) for the femur repair. For the radius fracture repair, report 25515 (Open treatment of radial shaft fracture with internal fixation), appending Modifier 79 to indicate that the surgeries were unrelated and the radius repair occurred within the 90-day global period of the femur repair.

Conclusion

Navigating the complexities of medical codes and modifiers can be challenging, and the only way to ensure full claim reimbursement is by using them correctly. With over 30 years of experience in the billing field, Stat Medical Consulting has consistently helped medical practices achieve their desired financial results. We are committed to reducing costs and securing full claim reimbursements. Our seasoned experts understand the nuances of medical billing and stay updated with the latest developments in the field.

If you are running a medical practice and struggling with high denial rates or worried about claim reimbursements, turn to us. We offer a free billing analysis, providing a thorough review of your claims before submission. Our experts will identify shortcomings and recommend necessary fixes, leading to a significant increase in your revenue.

Let us help you achieve full claim reimbursement and improve your financial outcomes.