Modifier 78: Case Study: Reason Decides Correct Modifier for Metatarsal Excision

Read this expert medical billing and coding advice before allocating a code for multi-step procedures.

When a patient comes with a severe infection, you have to deal with numerous treatment steps -- and numerous potential complications for your coding. Test your medical billing and coding know-how by reviewing this scenario and determining the accurate modifiers when three distinct surgeries are required.

Scenario: An established patient who has peripheral neuropathy comes with a severe foot infection. During the evaluation and management, the podiatrist accomplishes a problem-focused exam and history to conclude that immediate incision and drainage is required (28003, Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas). He then concludes to wait for the infection to recede to see if any further procedure is needed.

Four days later, the podiatrist determines that he needs to further excise bone from the second and third metatarsals (28122, Partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus). The wound is left open for one week to drain the infection before the podiatrist performs a secondary closure (13160, Secondary closure of a surgical wound or dehiscence, extensive or complicated).

Your task: Decide what modifiers will get to the bottom of payment for these procedures.

Medical Billing and Coding Expert Advice: Don’t Forget Your E/M

Prior to deciding on correct modifiers for the excision as well as secondary closure, you want to make certain you’ve covered all your bases coding the initial patient encounter.

In case you just reported 99212 for the E/M accompanied by 28003 for the I&D, you’d be asking for a denial. You should append modifier 57 (Decision for surgery) to the E/M code to let your carrier know that the visit encompassed a separately identifiable service, and not merely a pre-op screening.

Remember to check your global for accurate medical billing and coding: In case the podiatrist carried out an I&D for merely one bursal space (28002), the 10-day global period of that procedure would lead you into appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). On the other hand, the 90-day global of 28003 ascertains it as a major surgery, necessitating modifier 57.

Medical Billing and Coding Tip : The 57 modifier is also applicable to E/M codes done the day before the major procedure. This is correct on condition that that the E&M code is important and distinctly identifiable.

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