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 KZA Alert: Modifier - 79 is a Target

Modifier 79 is a target!

Here’s the scoop.  CMS issued a transmittal – number 442 to be exact about practices submitting modifier 79 inappropriately during the global period.  If you don’t know what modifier 79 is – you are potentially in trouble so read on!

The OIG is also on the case – so it must be a common and expensive error to attract all of this attention.

Here’s the short story:  Medicare directed all plan contractors to tighten internal controls by:

  • Reviewing their Modifier 79 claims data.
  • Taking the appropriate action consistent with their internal strategies, which means looking at prepayment edits.
  • Making pre and post reviews based on their internal analysis.

Okay, that’s what they’re doing.  So what should you do right now?

1. Run a CPT frequency report, YTD and LYTD to see how many times modifier 79 was appended to a surgical service.  If there are a large number of these, go to step 2.

2. Now you need to see why the modifier was used.  Pull several cases and verify 79 was used correctly.  In our consulting experience, it’s often mistakenly appended.  For instance, let’s say there is a post op hematoma on day three after a major procedure with a 90-day global period.  We would not expect to see a claim reporting:

10140-79  drainage of a hematoma, seroma or fluid collection
Why?  Consultant Mary LeGrand explains:  Modifier 79 is appended when the service is unrelated to a surgical procedure in a global period.  While there are those who advise that a diagnosis of hematoma or seroma is ‘different’ than the diagnosis for the primary procedure you need to stop there.  While the diagnosis seems unrelated, using it is not appropriate.  If the patent is returned to the OR for the drainage of the hematoma, modifier 78 is the correct modifier, as it describes an unplanned return to OR following an initial procedure.  I strongly recommend that coders review the definitions of 78 and 79 carefully.  If the hematoma is drained in the office setting, the service is part of the global surgical package and not separately reportable according to Medicare.

3. Get help.  You can attend one of your Academy or Society’s training sessions, which KZA teaches.  Or, if there are a large number of claims, you may want an outside review – and yes, we offer that service.  If you choose this option, we strongly recommend that your healthcare attorney request all post-submission audits.  Reason should be obvious.

And, for heaven sakes: if you don’t know about RAC and CERT audits – learn about them now.  This is not kid stuff.  The auditors are paid based on what they find.  Are they motivated?  We think so.  However, we know of no AIG executives who’ve moved over to the coding review business – yet.  Stay tuned.

Go to our website for more information on the courses.
Call Colleen Gallagher or Sarah Hoke at 312.642.5616, if more personal attention to your issues is required.

Upcoming courses are also available through the American College of Surgeons.
Stay tuned:  Modifier 24 is also in the crosshairs.  To be discussed in out next ALERT.
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