Modifier 79

Modifier 79 Description, Uses, Guidelines & Examples (2022)

Modifier 79 appends for service when the physician performs an unrelated procedure or service by the Same Physician during the postoperative period.

Modifier 79 Description

Modifier 79 indicates when the same physician performs a service unrelated to prior surgery or procedure. Modifier 79 applies when service to show previous surgery is entirely irrelevant and served only during the postoperative period.

Modifier 79 indicates another unplanned surgery or service performed by the physician or a skilled professional during the postoperative period of an initial procedure. For example, the patient had a surgical procedure on the right shoulder and may present again and require a service for complications developed in the prior surgery.

Modifier 79 does not apply to the Evaluation and Management CPT codes (99201-99499). Therefore, it is appropriate to append modifiers 24, 25, 57, etc., when E/M visits bills for the service. 

Modifier 79 frequently bills with surgical procedures when the physician requires repeat service for an unrelated condition of initial surgery.

Modifiers 78 and 58 apply when related to or staged procedures performed by the physician. Modifier 79 is only applicable when service renders in a 10 or 90 days global period, and it is inappropriate to bill for a related service or previously scheduled service. 

Modifier 79 bills more often with surgical procedure codes as CPT codes range from 10000 to 60000 procedure codes and may report with radiological service if the insurance or third-party payer requirements.

Unlike modifier 78, 79 leads to full reimbursement by the insurance or third-party payer. Documentation must support the service is irrelevant to the prior surgery during the postoperative period.

What Is Modifier 79?

Modifier 79 represents the service when the same physician performs service for an unrelated procedure to prior surgery or procedure. It attaches with the service to show previous surgery is entirely irrelevant. It is applicable in the postoperative period only.

When To Use Modifier 79

Modifier 79 appends with the service when the physician does not plan the procedure, and the patient returns to the provider for a condition unrelated to the prior surgery. For example, the patient may have developed an infection from a shoulder injury and previous procedure related to the knee.

The second procedure must be unrelated to the prior service or surgery to append 79.

Modifiers 78 and 58 may apply instead of 79 when the physician provides the surgery or procedure related to the prior surgery.

Unlike Modifier 78, Modifier 79 does not influence when the physician plans the service or not, as it is unrelated to the prior services.

The service must render by the same physician when 79 attaches to the service, and It is inappropriate to append 79 with a different provider.

Modifier 79 applies when service is performed during the postoperative modifier, while modifier 59 applies when the same physician performs a particular service on the same day.

79 modifier

Modifier 79 Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

Modifier 79 applies with service when the physician performs an unrelated procedure or service during the postoperative period. It is appropriate to append a modifier 58 instead of 78 when the physician performs related unplanned or staged service. 

79 Modifier is irrelevant to attach with the related service to the prior surgical procedure, and it is appropriate to append modifier 78 with that service instead of 79.

Modifier 79 is only applicable when the physician performs the service during the 10 or 90 days postoperative. Therefore, it is inappropriate to append 79 on the day of surgery or after the postoperative period.

79 Modifier is appropriate when the patient presents with a different diagnosis in the postoperative period. For example, a physician performs the first procedure with a Malignant neoplasm of the lungs, and the subsequent performs on the same patient with a liver tumor. 

Modifier 79 is only applicable when the same physician performs the service during the 10 or 90 days postoperative. Therefore, it is inappropriate to append 79 when furnished by a different provider.

79 does not apply to evaluation and management procedures (99201-99499). It is appropriate to report with E/M Modifiers 25, 24, 57, etc. Modifiers 79 and 24 are used almost for the same purposes, but the main difference is the CPT code range. Modifier 79 applies with surgical procedure codes, while modifier 24 appends with evaluation and management visits by the same physician. 

Modifier 79 is only applicable when the same physician performs the service other than in the operating room during the 10 or 90 days postoperative. Therefore, it is inappropriate to append 79 when furnished in the operating room.

Modifier 78 vs 79

Modifiers 78 and 79 apply when the same physician performs the service during the postoperative period. Modifier 78 is appropriate when the physician provides service to the patient for an unplanned return to the operating room following the initial procedure for a related service during the postoperative period.

In Contrast, Modifier 79 append with services unrelated to the procedure or service performed in the postoperative period. It usually represents the unrelated procedure to the prior surgery within a ten or 90-day global period.

For Instance, the physician saw the patient during the postoperative period and performed an Umbilical hernia repair procedure before this encounter, which has 90 days global period. The patient needs another service because an infection developed on the surgical site, and it was not a planned return. Therefore, it is appropriate to report the other procedure with Modifier 78.

Similarly, suppose the Patient returns to the provider for an unrelated procedure in the postoperative period, such as a malignant tumor excision of the head region. In that case, it is entirely unrelated to umbilical hernia repair, and It is appropriate to report tumor excision of the head region with 79. 

Modifier 79 Examples

The Following are the examples of when 79 appends with the CPT codes:

Example 1

A 36-year-old male presents to the office for lesion removal on the trunk region on April 4, 2022, and has KNEE ARTHROSCOPY/SURGERY on March 1, 2022. The physician performed the procedures which are unrelated to KNEE ARTHROSCOPY/SURGERY.

The physical exam revealed that the patient had no other problems with eyes, nose, head, swelling in both upper and lower extremities, and denies nausea, vomiting, and fever. Nevertheless, the physician orders a series of diagnostic tests, the US, X-ray, and MRI of the Knee joint to identify the problems, requiring arthroscopy of the shoulder region.

Modifier 79 appends the procedures performed on April 4, 2022, to unbundle the service with CPT code 29881, which has a 90-day global period. It will start a new global period for this service if applicable. It will lead to full reimbursement from the insurance and third-party payer.

Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer.

Example 2

A 46-year-old male presents to the physician for an emergency department visit on December 2, 2022, with a shoulder arthroscopy procedure and had an Inguinal hernia repair on January 23. The physician performs the operation, which is unrelated to the prior surgery.

The physical exam revealed that the patient had no other problems with the head, swelling in both upper and lower extremities, nausea, vomiting, and fever. Nevertheless, the physician orders a series of diagnostic tests, CT and MRI of the shoulder to identify the problems, requiring arthroscopy of the shoulder region.

Modifier 79 appends to the procedures performed on December 2, 2022, to unbundle the service with CPT code 49505, which has a 90-day global period. It will start a new global period for this service if applicable. The insurance and third-party payer may reimburse full payment for the Knee procedure.

Documentation must support the medical necessity of these two services, inguinal hernia repair and shoulder arthroscopy, entirely unrelated by the same physician for accurate reimbursement by the insurance or third-party payer.

Example 3

A 76-year-old male presents to the physician for – Combined right and left heart catheterization and had an ED visit for a Knee procedure and Enterectomy by the same physician 60 days ago. The physician performs the operation, which is unrelated to the prior surgery. 

The physical exam revealed that the patient had no other problems with the chest, swelling in both upper and lower extremities, abdominal pain, nausea, vomiting, and fever. Nevertheless, the physician orders a series of diagnostic tests such as Mri and CT of the knee to identify the problems, requiring an arthroscopy procedure.

79 appends to the procedures performed today to unbundle the service with CPT code 44120 performed 60 days ago, which has a 90-day global period. It will start a new global period for this service if applicable. It will lead to full reimbursement of knee arthroscopy procedures from the insurance and third-party payer.

Documentation must support the medical necessity of these two services, such as Enterectomy and Knee arthroscopy procedures entirely unrelated by the same physician for accurate reimbursement by the insurance or third-party payer.

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